Gaining an Edge on More than Just Fraudsters

Transcription

1 Gaining an Edge on More than Just Fraudsters Presented by: Kelli Garvanian Webinar date: May 21, 2013 The information and materials provided and referred to herein are not intended to constitute legal, regulatory, accounting, medical or financial advice and do not create an attorney-client or other fiduciary relationship between Emdeon or its representatives and any third party. Additionally, Emdeon does not guarantee the accuracy of the information contained herein. The interpretations, extrapolations, views and opinions of each individual presenter are not necessarily the views of Emdeon. Emdeon disclaims any and all liability for any reliance you may place on the information contained herein. 1

2 About our Speaker Kelli Garvanian Business Development, Emdeon Kelli is Emdeon s resident expert in healthcare fraud in health, life, dental and disability insurance. With more than 30 years experience in the industry, Kelli frequently serves as a lecturer for AHIP s education and training courses on fighting healthcare fraud and holds designations of Accredited Health Care Fraud Investigator, Health Care Anti-Fraud Associate and Certified Fraud Examiner. 2

3 Fraud, Waste and Abuse The Numbers Dollars lost to fraud, waste and abuse is estimated to be as high as 10% of our nation s annual health care expenditure over $260B per year NHCAA (National Health Care Anti-Fraud Association) estimates more than 3% of annual claim payments are lost to fraud. Industry estimates have ranged 3%-10% for many years Fraud accounts for 19% of the $600B to $800B in waste in the U.S. healthcare system annually, and amounts between $125B and $175B annually (Thomson Reuters, 2009) That s on top of payment errors: In 2011, GAO found an 8.6% claims processing error rate in Medicare FFS ($28.8B in improper payments). In Medicaid, the error rate was 8.1% ($21.9B in improper payments), and Medicare Advantage had an 11% error rate ($12.4B in improper payments) 3

4 Government Action Affordable Care Act = Toughest piece of antifraud legislation ever written CMS collects record-high $2.29B in overpayments (Fierce Healthcare 12/4/12) Three times more than last year's $797.4 million recoupment of overpayments 4

5 The shift to pre-pay avoidance is on Government CMS needs to do more to combat healthcare fraud MACs may initiate pre-pay review if they suspect providers are not billing properly ZPICs Fraud fighters Pre-pay reviews based on data analysis and other triggers States various recent pre-pay exploration efforts 5

6 The shift to pre-pay avoidance is on Commercial Plans Finding better and faster techniques for prevention and early detection of fraud. What do you foresee as the biggest challenges with health care fraud over the next 5 years? Moving from primarily retrospective to primarily prospective. Ability of insurers and the claims systems to quickly react to fraud in a prepayment environment. Electronic claims submission and the increasing emphasis on timely processing of claims required by various state mandates. Developing systems that can identify fraud proactively. Source: Research Brief: Insurers Efforts to Prevent Health Care Fraud by AHIP Center for Policy and Research (Survey - January 2011) 6

7 Ideal Payment Integrity Program: Must Have s Multiple layers of integrated detection technology Defensible Hybrid Approach Highly skilled, experienced teams & networks Big Data Case management system Highly customizable solution Dynamic reporting capabilities A platform that can quickly deploy rules Cooperation & coordination between departments 7

8 Let s run a real-world scenario. Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient 181 days out in a 12-month period he billed 25hrs of service per day License has been suspended, so he is billing services under a partner physician s ID In addition to the services received at Dr. Anderson s office, 70% of his patients were also receiving high-cost injectables from various facilities and institutions 8

9 What s wrong with this picture? Primary treatments to patients are for fatigue and anti-aging. Typically, an Allergist would treat patients with allergy symptoms; sneezing, difficulty breathing, cough, watery eyes, etc. 9

10 What s wrong with this picture? Primary treatments to patients are for fatigue and anti-aging. Odd no children or men? Unusual that the demographics of the patients is not more broad. 10

11 What s wrong with this picture? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Only two codes seems irregular and this is an outlier. Allergists treat a number of varying conditions, yet he only bills 2 (allergic rhinitis/ runny nose) and (asthma not otherwise specified). 11

12 What s wrong with this picture? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient That s FIVE TIMES the amount of units per patient billed by Dr. Anderson s peer group (average is 42). 12

13 What s wrong with this picture? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient 181 days out in a 12-month period he billed 25hrs of service per day I know our government extended daylight savings time, but last time I checked, there s only one day each year that technically has 25hrs in it 13

14 What s wrong with this picture? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient 181 days out in a 12-month period he billed 25hrs of service per day License has been suspended, so he is billing services under a partner physician s ID Ok, the Bad Boys, Bad Boys theme song should be playing right about now. 14

15 Comparison of Billing Trends Dr. Anderson and his Partner $120,000 ROBY ANDERSON $100,000 PARTNER Paid Dollars per Month $80,000 $60,000 $40,000 $20,000 $0 15

16 What s wrong with this picture? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient 181 days out in a 12-month period he billed 25hrs of service per day License has been suspended, so he is billing services under a partner physician s ID In addition to the services received at Dr. Anderson s office, 70% of his patients were also receiving high-cost injectables from various facilities and institutions Since the treatments that he provided were supposedly injections, why the need for these patients to go to an institution and then get high cost injectables for completely different diagnosis. 16

17 Ok, that s great. But how can I flag all of that? Primary treatments to patients are for fatigue and anti-aging. 17

18 Ok, that s great. But how can I flag all of that? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes 18

19 Ok, that s great. But how can I flag all of that? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient 19

20 Ok, that s great. But how can I flag all of that? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient 181 days out in a 12-month period he billed 25hrs of service per day 20

21 Ok, that s great. But how can I flag all of that? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient 181 days out in a 12-month period he billed 25hrs of service per day License has been suspended, so he is billing services under a partner physician s ID 21

22 Ok, that s great. But how can I flag all of that? Primary treatments to patients are for fatigue and anti-aging. 99.9% of the services were filed under two diagnosis codes Billing an average of 210 units per patient 181 days out in a 12-month period he billed 25hrs of service per day License has been suspended, so he is billing services under a partner physician s ID In addition to the services received at Dr. Anderson s office, 70% of his patients were also receiving highcost injectables from various facilities and institutions 22

23 Fully Integrated Payment Integrity PROVIDERS EMDEON PAYER Receive Claim Adjudicate Claim Pay Claim Single Source Claims COST MANAGEMENT INTERFACE Post-Adjudication/Pre-Payment Post-pay Audit & Recovery Pre-pay Fraud and Abuse Detection Clinical Code Edits/ Duplicate Detection Complex Claim Review Medicare & PPO Routing and Repricing Cost-based Fee Negotiations Clinical Code & Duplicate Review DRG Audit Contract Compliance Audit Contract Repricing Hospital Charge Audit FWA Review & Investigation Refund Recovery Services Third Party Liability 23

24 The Emdeon Difference Single Source Multi-payer Data Offers Holistic View Volume Appreciation for Provider Sensitivity Experience Flexibility Significant Savings & Recoveries Flexible Pricing SaaS Technology Multiple layers of claims cost management technology from a single partner. Leverages over 1 billion claims from multiple payers for deeper data mining and more intelligence Screen over $80 billion in paid claims post-pay and $60 billion in paid claims pre-pay FWA and repricing solutions each year Successful track record without disrupting valuable provider relationships; less than 1% appeals and overturn rate on respective findings 20 year successful track record in post-pay audit & pre-payment avoidance payer clients nationwide. Tailored services custom designed to help you meet your claims cost management goals.5 2% incremental savings and recoveries on average Contingency model, fixed fee or PMPM Quick deployment, always current, updates every two weeks, no software maintenance 24

25 Thank You 25