Meeting your organization’s Program Integrity goals is a challenge - and balancing the need to show improved detection, prevention and recovery results with constrained budget and resources is one of the biggest. To keep up and improve results, you need to need a combination of PI domain experts and the most advanced methods and tools you can find. Again, that can be a challenge in today’s competitive employment world and ever-evolving technology scene.
Truven’s Vulnerability SaaS offering is the solution to these challenges. Our outsourced FWA detection solution leverages Program Integrity domain experts, leading detection analytics, and an efficient operating environment to meet your needs. Our PI staff have decades of experience in Program Integrity analysis and investigation. They leverage our Payment Integrity Algorithm Library, which contains hundreds of thousands of edits and audits (e.g., NCCI, global surgery periods, medically unlikely edits, mutually exclusive services, etc.) and hundreds of proven fraud algorithms like “Services after Death” and “Ambulance Trips to Nowhere”.
We deliver web-based, summary level executive dashboards displaying all of your providers results as well as a detailed Assessment Results and Recommendations Report containing:
- An Executive Overview defining the work completed, high level findings, and recommendations for next steps
- Description of the analytics performed
- Summary of findings that identify all potential overpayments by the categories of:
- Recoverable: Claims that may warrant overpayment recovery activity.
- Billing Error: Claims that contain coding errors or otherwise appear to have been miscoded.
- Long Term Savings Opportunity: Claims that would be denied in the future, if new policies, procedures, edits, education or other activities are put into place now.
- Interesting Observations: Claims unlikely to be recoverable or actionable at this time.
- Software-as-a-Service (Saas) outsourced solution has zero hardware expense and software footprint to you Algorithms are already developed and can be deployed quickly
- Delivers solid leads and identifies claims overpayments immediately, resulting in maximum return on investment quickly, with ability to expand incrementally to meet your needs
- Fraud leads will be identified, as well as policy weaknesses
- Allows you to clearly target suspicious behavior by both providers and members, and then easily investigate and document the specific activities
- Information is used to support recoveries and to implement prepay cost avoidance strategies.
- Our fraud and abuse algorithms look at fraud within ALL claim types (professional, facility, drug, durable medical equipment, nursing care, home health care, ambulance, hospice, inpatient, outpatient) AND link these claim types together to find problems that only cross-claims linkages can detect (like patients getting home care while they are in a hospital or nursing home)
- We utilize experienced algorithm developers and employ a 100% peer review process of all developed data processing scripts.