Identifying Medicaid Fraud and Validating 3rd Party Payments Through Powerful Analytics

by | Dec 9, 2017 | Case Studies

SITUATION:

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 SOLUTION:

Phase 1:

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.

Phase 2:

Search strategies going back 5 years from the dates of service were then formulated to identify recoveries and capture overpayments.

Phase 3:

Once fraud and non-continuity delivery domains were identified, Plan2Account developed a contract structure for categorizing provider information for relevant non-fraud applications.

Phase 4:

Plan2Account performed a population health strength analysis of the most active targets identified.

CLIENT RESULTS:

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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