The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

 
By Truven Staff

Using Algorithms and Predictive Models to Find Abuse and Fraud

David Nelson imageA critical success factor in any program integrity effort is applying the appropriate algorithms and predictive models in pre-payment and post-payment claims analysis environments. Truven Health Analytics has experience developing and cataloging hundreds of algorithms which have been used (and are currently used) in various state agency, federal agency, health plan and employer operations to detect abusive and fraudulent claims schemes. We have also seen predictive model intelligence growing in the marketplace, and we are helping payers improve their predictive models so that they more effectively fight fraud and identify high risk claims before the claims are paid. While these sophisticated approaches are implemented to find what we didn’t see before, we also see our clients achieving results every year with some of the tried and true detection algorithms. Each year our expert panel – a team that works with payers across the healthcare spectrum every day – selects a set of key algorithms. We just presented a webinar on the Key Algorithms for 2014, and the presentation included:

  •  A new approach to the overuse of modifiers. We focused on modifiers 22, 24, 57, 76, and 77.
  • The device malfunction algorithm which identifies claims where the reason for treatment or services rendered is due to a malfunctioning implanted device
  • Extended DME rental use
  • Over utilization of diabetic supplies
  • Critical care on date of discharge
  • Advanced life support (ALS) transportation without an inpatient stay
  • Hospital acquired conditions
  • Over utilization of lumbar MRIs
  • Lumbar MRI, post lumbar MRI, or CT
Some of these algorithms represent new schemes we are seeing, and some represent schemes that continue to produce analytic results that PI units and Special Investigation Units (SIUs) can take action on and make recoveries. Our team has produced the Key Algorithms list annually since 2003 to support the healthcare payer community that is dedicated to improving integrity and eliminating fraud, waste, and abuse in healthcare. If you would like more information on algorithms and predictive models, feel free to reach me at david.nelson@truvenhealth.com.

David Nelson
Vice President, Market Planning & Strategy
4111
Categories: Government

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