As a stand-alone offering, Detection Services provide fully developed and supported intelligence for medical, facility and pharmacy claim and eligibility FWA. This includes:

• Executive reports on subjects/schemes that present the greatest risk of FWA
• Risk ranking by provider
• Detailed risk-analysis results by provider
• Detailed claim data reports by provider. These identify specific claims at risk
• Internal and external supporting documentation

Our objective is to provide the most valid leads with minimal false positives. We achieve this by combining these analytical approaches:

• Rules-based peer-review, utilizing IBM FAMS 8,000 fraud algorithms and advanced data-mining capabilities, which identify specific FWA patterns.
• Link analysis, which identifies statistically significant relationships among data sets.
• Clinically based risk-adjustment, using Johns Hopkins' Adjusted Clinical Groups (ACG's). This helps identify discrepancies between providers' patient morbidity and utilization patterns.
• Macro and micro trend analysis, which identifies significant upward and downward billing patterns indicative of FWA.
• Ad-hoc queries, which respond to emerging FWA billing issues.

Benefits

• Generates highly qualified leads with minimal false positives
• Provides easy-to-use reports regarding FWA risks
• Ranks providers with respect to risk
• Delivers supporting documentation