Verizon and LexisNexis have showcased software to help the health care industry curb medical claim fraud that costs government and commercial insurers billions of dollars.
and LexisNexis have demonstrated software platforms to
help government agencies and commercial health care organizations use data-analysis
techniques to uncover medical claim fraud.
Both companies displayed
their anti-fraud products at the National Health Care Anti-Fraud Association
(NHCAA) Institute's Annual Training Conference in Atlanta, which runs from
Verizon Fraud Management for
Healthcare uses predictive-modeling algorithms to identify potentially
fraudulent claims in real time and send them to case managers to be screened,
Verizon reports. Connected Health Solutions is Verizon's subsidiary that offers
IT and consulting services for the health care industry.
As in financial services and
telecommunications, predictive modeling involves advanced algorithms and
analytics. Companies can analyze health care claims and transactions to screen
large amounts of data in real time for fraud, according to Verizon.
Meanwhile, LexisNexis Risk Solutions
division of publisher Reed Elsevier, demonstrated its Social Network Analytics
software, which the company launched in 2010.
With Social Network
Analytics, health care organizations can use predictive analytics to uncover
hidden relationships in the claims process among medical providers and other
entities to stop unlawful payments, according to LexisNexis.
Analytics represents the latest frontier in technology solutions that enable
members of the health care industry to identify and prevent fraud, waste and
abuse," Bill Fox, senior director for health care at LexisNexis, said in a
collusive health care fraud is critical to stemming health care fraud and
protecting consumers, medical providers and government and commercial
payers," he added.
Fraud adds $260 billion, or
10 percent, to expenditures in health care per year in the United States,
according to 2009 U.S. Department of Health and Human Services statistics.
Verizon Fraud Management for
Healthcare, launched Nov. 16, relies on patented algorithms to find anomalous
data patterns in transactions. Features include a risk-scoring module,
real-time continuous monitoring and data integration with a health care
organization's IT systems.
"Predictive modeling in
real time can stop the payment from being made," Connie Scheyen, managing
principal for Verizon Connected Health Solutions, told eWEEK
Suspicious incidents include
claims for treatment not medically necessary, stolen identities and falsified
billings, Verizon reports.
Algorithms could detect when
a doctor bills for extra patients than they'd normally see-
such as 100 a day, Scheyen explained. Other warning signs would be
several health care providers in one area seeing a patient on the same day, Scheyen
The software's geomapping
features can even spot false storefronts of pharmacies or health care
Fraud Management for Health
Care is highly scalable, meaning it can adapt to any type of health care
organization, Scheyen said.
It provides an alternative
to the usual "pay and chase" process, in which payers make payments
and then need to recover the funds later, Scheyen explained. "What Verizon
brings is prepayment intervention capability," she noted.
Medical equipment purchases
account for 30 percent of health care fraud, according to Scheyen.