Identifying Medicaid Fraud and Validating 3rd Party Payments Through Powerful Analytics
A Medicaid HMO required a claims audit and transactional review of a 40,000-patient base. They desired a vendor who could both audit and identify transactions matched to a referral from the primary care Electronic Medical Record (EMR) software system.
Plan2Account performed a complete review of payment and EMR domains to identify key features pertaining to issues, which were listed out in their semantic variations.
Search strategies going back 5 years from the dates of service were then formulated to identify recoveries and capture overpayments.
Once fraud and non-continuity delivery domains were identified, Plan2Account developed a contract structure for categorizing provider information for relevant non-fraud applications.
Plan2Account performed a population health strength analysis of the most active targets identified.
The client received a data-based strategy linking the referral process, claims payment and EMR software along with a complete fraud analysis of Medicaid industry issues. As a result, three primary care physicians were identified as fraudulently writing prescriptions, and further deceit was avoided.
Plan2Account validated 3rd party payments and recovered $3.5 million in overpayments for the client.
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