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This is a presentation deck given by Karthik Balakrishnan, Ph.D., covering Verisk Health's cross-payer data solution for healthcare fraud, waste and abuse.
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CollaborationIs KeyTransforming the Fight Against Fraud Through Shared Data and Ideas
1November 7, 2013
Presented By
Karthik Balakrishnan, Ph.D.Sr. Vice President, Fraud Solutions and Analytics
2
Jeff YoungVice President, Fraud Control
About Verisk Analytics
Publicly-Traded
Focus on The Science of Risk
Financial Services
Property & Casualty
We drive performance in the business of healthcare. By combining clinical and analytics expertise with advanced technology and services, we help payers, employers and providers solve complex problems with measurable results.
$10.2B Market Cap
15.7% Annual Growth 2009-2011
Supply Chain
Healthcare
3
• $234B – Healthcare fraud & abuse
• A big problem becoming bigger
• Payer Siloes limit efficacy of FWA detection and prevention
• Many suspect schemes cannot be detected in a payer silo
• Cross-Payer Data Pooling• Challenging to do, but can offer tremendous new insights and
capabilities to further the fight against fraud
• Reality or just a concept?
4
Pooled Data Background
• Specialty: Family Practice
• State: Florida
• Payer A – billed $200K in the last 2 years• 3-8 hours of treatment per day
• Cross-Payer Exposure• Payer B – billed $360K in the last 2 years• Payer C – billed $520K in the last 2 years• Payer D – billed $270K in the last 2 years• ..
• < 10 hours a day for any one payer Only time-based codes
• Pooled data shows• 50% of all dates of service: 10.25 - 56.75 hours billed• 32% of all dates of service: 20 – 56.75 hours• 14% of all dates of service: 30 – 56.75 hours
• $2.6M – Exposure across payers in last 2 years • 70% - percent of days only one or two payers were billed
5
Payer A
Payer B
Payer C
A provider billing for more than the number of hours in a dayThis scheme would be impossible to detect in a payer silo without cross-payer pooled data
The Man Who Defied Time
How Did We Get Here?
INDEX SYSTEM1930s
25 Million Queries
850 Million Claims
90% Participation
1 Unified PlatformClaimSearch1999
• 850 million claimsIndustry’s only comprehensive property & casualty claims database
• +90% participation Of the P&C industry (by DWP volume)
100% of the top 10
• +85,000 Active System Users
• 25 million Investigation Queries (IQ) performed annually
INDEX, PILR, MIB
2005FraudFinder Pro Released
2009AMD Conceived
2011AMD Launched
1076Providers Referred
70% of Auto carriers20% of Workers Comp carriers
Already Aggregated MedAware Alerts Issued 441
Clinics Identified694
In Identified Exposure$191M
NICB Successes
Plan Reporting Requirements
Case Tracker
DATA
ANALYTICS
ANALYTICS
SIU
Law Enforcement Data Provisioning
MEDICAL + RX DATA
Case Outcome Feedback
PA
YE
R
PA
YE
R
SIU
Cross Payer Advanced Analytics
ENTITY RESOLUTION
Cross Payer
Payer
Cross Payer
Suspect Providers
TOUCHHuman
Case Tracker
Suspect Provider Database
Feedback to Enhance Analytics
Suspect Entity Compliance Reporting
Cross-Payer Case Referral
Suspect Referrals
ID Theft
Alerts
Cross Payer Suspect Provider
Alerts
State MedicaidCMS
Collaboration
2012Alliance Initiated
2013Alliance Launched
Founding members include:
8 Million Lives
41 States
800K + Providers
14
Healthcare Payers
Pooled Data Fraud Analytics
Collaboration Tools
The Alliance is Operational
WhatWe’re Finding
INDEX becomes Part of ISO1999Case
Study 1
Impossible Hours
Specialty: Orthopedic Spinal Surgeon
Location: Texas
Trigger: High Billing Hours
• Findings
• 11.25 Hours billed to plan A• 11.25 Hours billed to plan B• 22.50 Total hours/daily (not accounting for pre- and post-service time)
$1,004,524Billed in Previous 12 Months
Date of Service
Tim
e in
Hou
rs
Avg.
INDEX becomes Part of ISO1999Case
Study 2
Provider Alert
Specialty: Cardiology
Location: Texas
Trigger: Excessive Cardiovascular Studies
• Findings
• Most patients have no prior history• Few receive follow-up care• Patients have same diagnosis• Split bills
$1,168,859Billed in Previous 12 Months
INDEX becomes Part of ISO1999Case
Study 3
Impossible Patients
Specialty: Immunology
Location: Texas
Trigger: High Billing Hours
• Findings
• High billing time across partners• 32.7 Average patients per day• 99th percentile in Z score
• $3,718,784 Billed in Previous 12 Months
WhereWe’re Going
20
Expand States
• Currently live in 12 states
Deploy New Cross-Payer Schemes
• Collusion analytics• Medical ID theft
Extend to Rx and Dental Data
Include P&C in Alliance
Next Steps
See You at NHCAA’s Annual Training Conference Booth #101
Thank You Questions?
?
Contact us: [email protected]
www.veriskhealth.com