2016 Sponsored Webinars
In the absence of fraudulent providers’ confessions, data analysis is the backbone of successful FWA investigations. As technology advances, so too does the creativity of unscrupulous providers, suppliers and fraudsters willing to exploit and misuse healthcare payer systems to gain improper payments. To continuously keep up, an ability to recognize red flags across various provider data sets is essential for today’s program integrity investigators. This session explores effective techniques for spotting red flags and using associated data analysis techniques, and detecting FWA across various provider specialties from different angles including pooling data, and use of public records and publicly-available data.
Participants will learn to:
- Understand the significance of commanding data analysis techniques to effectively combat fraud, waste and abuse (FWA);
- Recognize red flags often associated with fraudulent activity across various provider specialties; and
- Understand the value and methodologies of conducting data analysis on pooled data for FWA investigations.
Service Delivery Manager, General Dynamics Health Solutions
Service Delivery Manager, General Dynamics Health Solutions
May 25, 2016
Verisk Health believes in a "no assembly required" approach to case referrals. The concept is simple: fraud, waste, and abuse (FWA) vendors should do the legwork to find and validate aberrant billing behavior, explore patterns, conduct pre-case research, and deliver all the right information to a special investigative unit (SIU) so that it can immediately open and pursue good cases.
Join this webinar to learn more about the turnkey allegation approach, including:
- The challenges that many SIUs face in building a case
- Best practices for shortening the path from lead to allegation
- Success stories
Ryan Cleverly, AHFI
Director of Fraud Operations, Verisk Health
Ron Lee, MBA
Compliance Supervisor, SIU, CalOptima
Shuying Shen, AHFI
Data Science Director, Verisk Health
Tiny Babies- Huge Cost: The NICU Impact on Overpayments and Fraud
This session will review the impact of premature births in the United States on the utilization and spend on Neonatal Intensive Care Unit (NICU) services. The speakers will discuss billing and payment methodologies and their implications for potential overcharges and overpayments, either as a result of errors or patterns of inappropriate billing. The session will demonstrate how robust analysis and focused audits can identify NICU claims with a likelihood of being billed at a higher level of care than was rendered, as well as instances where treatment in the NICU unit was not medically necessary. The participants will learn the methodology behind these types of audits, the courses of action taken to identify NICU services paid inappropriately and the medical review process.
Through this session, participants will:
- Learn about the process, guidelines, and rationale behind billing and payment for NICU admissions
- Understand the associated payment methodologies used and key items to analyze to discover suspicious billing in each key methodology
- Hear about best practices and strategies for validation, auditing, investigation, and recovery
James Wood, M.D.
Medical Director, SCIO Health Analytics
SVP Payer Solutions, SCIO Health Analytics
July 20, 2016
The terms big data and analytics have both become very nebulous within the health care payer industry. Depending on the context, many payers believe that they are using these technologies together with their claims data, to link providers and patients together. However, many are only scratching the surface leaving them exposed to substantial financial and reputational risk.
People are complex as are the relationships they build. Claims data provides a limited view into the associations and relationships that may be costing you millions in fraud, waste and abuse. Join this webinar to:
- Explore how big data, linking analytics and visualization technologies should work together
- Discuss real-world examples of how linking analytics uncovered suspicious address schemes, social clusters of hydrocodone, DME fraud, pill mills and more
August 31, 2016
While auto-adjudication methods capture a large share of medical claim errors, there are some claims processed through these rule engines that appear valid when they aren’t. These claims, if left uncorrected, contribute to wasteful or abusive billing practices—in some cases amounting to many millions of dollars. With the ongoing challenges of resource constraints and potential provider abrasion, you may believe that it’s impossible to review every suspect claim, but there is a way.
In this webinar, presenters will explore how to address all types of erroneous claims, specifically focusing on:
- The issues inherent in clinically complex claims and why automation fails to provide the level of attention that these issues need
- The latest examples of improper payment of clinically complex claims
- Best practices for the clinical validation of claims without burdening your organization
Vice President, Claim Accuracy Solutions, Verscend
Vice President, Clinical Performance, Verscend
Caryn Slack, MD
Senior Medical Director, Verscend
Vice President, Payment Integrity, Centene
SCIO Health Analytics
September 15, 2016
With healthcare’s growing reimbursement complexity and the rise of inappropriate healthcare expenditures, now is the time to consider additional data sources and analytics to enhance your FWA programs and processes.
This session will discuss the need to progress beyond claim level analysis for FWA and the importance of leveraging predictive models, member/provider profiles, and rich multi-source data to identify FWA patterns, reduce errors, limit false- positives, and improve overall performance recoveries.
Join your peers and leaders from SCIO Health Analytics for a discussion of new and emerging challenges facing payers, how recent thinking can address those obstacles, and exemplar use cases.
More specifically, webinar participants will:
- Understand the impact of analytics and profiling on FWA
- Discuss how to apply predictive models and rich data benchmarks to better identify true outliers
- Describe innovative approaches which leverage data analytics to drive behavior modification
Senior VP, Payer Solutions, SCIO Health Analytics
Rena Bielinski, PharmD, AHFI
Senior VP, Strategic Accounts, SCIO Health Analytics
October 19, 2016
Claims data can often hide significant fraud, waste and abuse schemes that leave your organization exposed to financial, reputational and member risks. During this webinar our fraud examiners will explore specific schemes we’ve identified across claims that are pitfalls for health plans.
Join us to explore key topics including:
- Multiple physicians billing for neo-natal critical care services;
- Hospitals with inpatient service in an outpatient setting;
- Claims for Clozapine for patients without an approved diagnosis; and more.
Truven Health Analytics
December 6, 2016
Join us Tuesday, December 6th, from 2:00 pm - 3:00 pm ET for our next installment of the Truven Health Analytics Government Expert series, and discover the latest innovations we’ve uncovered in fighting fraud, waste and abuse in a managed care environment, including predictive analytics, algorithms, oversight and reporting.
Truven Health best practices will be shared on closing the gap between needing to reduce waste and abuse in the managed care environment — and the ability to do so successfully and cost-effectively while ensuring MCOs actively engage in program integrity. Additionally, attendees will learn about new fraud schemes and trends, and technical and analytic detection approaches.
Truven Health Analytics speakers include David Nelson, Mark Gillespie, Jillian Scalvini and Dennis Garvey, former Program Integrity Director for the state of Tennessee.