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how far can automated claim editors go? three fast facts you should know

Posted by Debi Behunin on 2/8/17 12:00 PM

There’s no question that automated claim editing is a crucial component of accurate and efficient claims payment. Using black-and-white sourced edits from the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association’s (AMA) CPT® book, as well as payer-sourced custom rules, these systems save plans a significant amount of money by keeping them from paying incorrect claims without human intervention.

But is having one automated claim editing system enough to ensure total claim accuracy, or are you leaving significant savings on the table without a secondary editor? And if you already have a secondary editor, is there a benefit to adding a tertiary editor? Here are three fast facts you should know about how far automated claims editors can go.

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the true costs of medical identity theft

Posted by Edie Hamilton, CPC on 1/11/17 11:07 AM

$13,500. That is the average cost victims pay to resolve medical identity theft—when they can resolve it.

Medical identity theft occurrences are becoming more common. Incidents increased 22 percent from 2014 to 2015, impacting more than 2.3 million people in the United States, per the Ponemon Institute’s Fifth Annual Study on Medical Identity Theft.

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are your improper payments hiding in plain sight?

Posted by Verscend on 10/5/16 10:17 AM

After years of focusing efforts on speeding up automated claim processing, most payers’ claim review systems have unintentionally let their guard down. As a result, improper outlier claims common to our industry continue to pass through automated systems right in plain view without getting flagged. For some payers, the impact can really sting, amounting to millions of dollars. Our latest infographic explores some of the most blatant examples of incorrect billing practices still going on today and what they may be costing you in inappropriate payments if not addressed.


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common FWA overpayments your automated claim editing system may miss

Posted by Verscend on 9/22/16 12:00 PM

The cost of healthcare continues to dominate headlines as the Affordable Care Act (ACA) expands managed care, and thus provides fraudsters with new opportunities to take advantage of the system. This new and complex healthcare landscape—along with its varied payment methodologies—has forced insurers to work more aggressively to contain their costs. One of the ways in which insurers can respond to this changing healthcare environment and address fraud, waste, and abuse (FWA) is by reducing billing errors.

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why "no assembly required" is a welcome phrase for fraud investigators and parents alike

Posted by Verscend on 7/27/16 10:29 AM

If you’ve ever purchased a bunk bed, swing set, or bicycle for your child, you likely recall the hours it took to progress from a neatly packaged box of parts to a finished product. The concept of “no assembly required” got us thinking a bit more about real-life, classic product assembly struggles and how they relate to everyday healthcare fraud, waste, and abuse (FWA) situations in which turnkey allegations could be helpful to special investigations units. 


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busted 2016: prominent healthcare fraud schemes

Posted by Verscend on 6/29/16 10:31 AM

The National Health Care Anti-Fraud Association (NHCAA) estimates that tens of billions of dollars are lost each year to fraudulent healthcare practices. Whether it’s intentionally defrauding a health plan or wasteful billing practices due to inattention, fraud, waste, and abuse (FWA) has grown too large to ignore. The U.S. Department of Justice, Federal Bureau of Investigation, and Centers for Medicare & Medicaid Services (CMS) often work in conjunction to pursue the largest fraud cases, resulting in the exposure of multimillion dollar schemes.

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how to fine tune your investigation approach

Posted by Verscend on 6/15/16 11:43 AM

For health plans’ special investigative units (SIUs), the notion of wading through a pile of false leads before finding actionable information may often feel like a waste of time. However, determining which case referrals to pursue doesn’t have to be a complicated and confusing process.

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fast-tracking FWA investigations with turnkey allegations

Posted by Shuying Shen, Tim McBride, and Ryan Cleverly on 4/28/16 8:11 AM

Healthcare fraud, waste, and abuse (FWA) investigators have a tough job. Keeping pace with the latest schemes, continuously weeding through hundreds of false-positive leads, and understanding the right time to pursue a case are just a few of the challenges a health plan’s special investigative unit (SIU) faces. When armed with the right pieces of information to immediately open a solid case, SIUs can quickly take intelligent action to educate providers, recover funds—or even prevent payment before it’s made.

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why collaboration is the next frontier of fraud, waste, and abuse prevention

Posted by Andy Tolsma on 12/21/15 2:22 PM

Andy Tolsma is a registered respiratory therapist with a degree in Health Services Administration. After 13 years of clinical practice, he moved into occupational health consulting and medical facility management. Andy then went to Sinclair Oil Corporation to manage both the company’s workers’ compensation and group health programs. Based on the healthcare claims administration model that he created at Sinclair, Andy continued on to build a commercial third-party administration company called P5 Electronic Health Services. Andy has also worked at Ingenix and managed a property and casualty clearinghouse. His most recent endeavor is to combine all of the experience he has gained across various industry roles toward improving medical fraud detection.

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supporting actionable FWA investigations with deep data

Posted by Shuying Shen on 11/18/15 11:45 AM

In the past ten years, healthcare technology has made significant advancements. Today, there are  Electronic Medical Record (EMR) systems in most hospitals and clinics that provide access to a host of patient information accessible online. With such a wide variety of data available and multiple ways to  access it identifying the latest patterns of fraud, waste, and abuse has grown complex. To narrow the  scope of data and quickly identify suspicious patterns, it is beneficial to create visualizations, such as  models and charts, which can help to illustrate a situation. Below are three commonly employed models  that analysts use to identify aberrant behaviors:
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