U.S. Fee-for-Service Medicine Model Becoming Extinct, Impacting Payment Integrity

by SAS

Changes in reimbursement models have brought new payment integrity challenges. There have been a number of them over the years. And how can you prepare for the associated data management and analytics challenges that are sure to follow? This article from BNA's Health Care Fraud Report, "U.S. Fee-for-Service Medicine Model Becoming Extinct, Impacting Payment Integrity", will help you understand what's coming - and how to prepare for it.

Public Records for Health Care

by LexisNexis

The United States now spends about $2.6 trillion annually on health care (17.5 percent of GDP) and with the reform initiatives under the Affordable Care Act (ACA), the number of Americans covered and the amount spent will grow dramatically, potentially leading to even greater fraud, waste and abuse in the system.

Revolutionizing FWA detection with a fully integrated software solution - FWAShield

by Healthcare Fraud Shield

Healthcare Fraud Shield is a provider of dynamic fraud, waste and abuse detection software solutions that have dominated the complex financial services industry over the past fifteen years. Our suite of products introduces several new technology applications to the healthcare industry that will revolutionize cost reduction opportunities. Read more to find out about our products and services.

Payment Policy Optimization: Blending Analytics with Rules to Prevent Wasteful, Abusive and Fraudulent Healthcare Spending

by McKesson

Curtailing the massive drain caused by FWA in healthcare has never been more important. New, more complex payment models are on the horizon, including bundled payments for episodes of care, and greater emphasis is being placed on payment for outcomes. In 2014, providers and payers will also be adjusting to ICD-10 coding. Experience has shown that each novel payment arrangement or code change presents new opportunities for confusion and abuse - for example, inadvertent or purposeful upcoding. This white paper by McKesson's Jim Evans looks at blending analytics with rules to prevent wasteful, abusive and fraudulent healthcare spending.

Case Study: Humana's Fight Against Fraud

by Verisk Health

"Humana wants to lead the industry in stopping fraud up front," says Jean Sexton, Area Director for the Humana Special Investigations Unit (SIU). Sexton asserts Humana's commitment to fighting fraud is long-standing and proactive. Rather than relying on data mining flags to simply stop damage from getting worse, Humana aims to eliminate fraud. Since implementing Verisk Health's fraud solutions, referrals to the SIU have increased steadily. Humana's referrals are up thirty percent from a year ago. According to Sexton, the dollar amounts decreased as the number of cases increased. "We're catching it up front so we're reducing waste caused by fraud."