Harness data to identify fraud and waste like perfect-game pitchers


Effectively harnessing data analytics within payer and provider organizations is kind of like pitching a perfect game in baseball--it's possible, but definitely not commonplace. Just like major league pitchers strive to achieve such a career highlight, payers and providers hope to employ data to better identify fraud and waste.

And just like big-leaguers can throw any combination of strikes and balls to reach one of the most elusive achievements in baseball, payers and providers can choose among a vast arsenal of available data sources, including electronic health records systems, predictive modeling software, anti-fraud programs and remote monitoring technology, to attain the rare accomplishment of using data to improve business.

Payers, in particular, have been upgrading their data programs and enhancing their analytical capabilities to combat fraud and abuse, control healthcare costs and ensure premium dollars are appropriately spent. "It's the natural progression in the field that we're going to use more and more analytics," Lee Arian, staff vice president of Indianapolis-based WellPoint's special investigative unit (SIU), told FierceHealthPayer for its latest free eBook, Payers and Providers: Using Data Analytics to Identify Fraud & Waste.

Blue Cross Blue Shield of North Carolina (BCBSNC), for example, uses predictive analytics to detect fraud. This "highly engineered fraud detection system" pinpoints patterns of suspicious behavior across claims and creates drilled-down reports by provider, patient, transaction and billing codes, BCBSNC SIU Director Gary Crispens says. The insurer's special investigation team uses the software to quickly guide investigators toward fraudulent activity with the greatest potential for recovery, thereby saving manpower and resources by avoiding chasing down activity unlikely to develop into a strong fraud case.

Meanwhile, accountable care and payment reform have compelled providers into a data-focused approach to improving healthcare quality and efficiency. But like payers, providers face their own set of challenges when it comes to data analytics, namely making sense of all the data collected. "It's getting the right data to the right person at the right time to do the right thing," says Stephen Stewart, CIO of Henry County Health Center, a 25-bed facility in Mount Pleasant, Iowa. "The challenge is how do you store it? And how do you move it to where it needs to be?"

Payers and providers alike could benefit from looking beyond their own healthcare industry to understand how data analytics can successfully revolutionize business. Case in point: the financial industry. "You can go to an ATM at any country gas station and get money out. So somehow they figured that out," says Chris Belmont, vice president and CIO for Ochsner Health System in Jefferson Parish, La. "I'm not willing to concede that [healthcare is] unique and this is just an impossible task."

So what should payers and providers look for in a data analytics program? Ralph Carpenter, head of Aetna's special investigative unit, says healthcare organizations should take four essential steps to ensure they purchase the most appropriate program for their specific use.

Or they could create their own in-house data analytics program like Cincinnati Children's Hospital Medical Center, which wanted a specialized application to help manage quality requirements, automate the collection processes and provide intelligence. When it couldn't find an adequate off-the-shelf solution, the hospital took matters into its own hands and created a software program in-house, says Frederick Ryckman, Cincinnati Children's vice president for medical operations.

Want to know more about Carpenter's recommendations or Cincinnati Children's in-house software building process? To read up on that advice and even more tips, including how big data could create more than $300 billion in value for the healthcare sector and which specialized routines Health Care Services Corp. has successfully run, check out FierceHealthPayer's free eBook, Payers and Providers: Using Data Analytics to Identify Fraud & Waste.

Then maybe payers and providers can feel the rush of that perfect game as they perfect their use of data analytics and successfully reduce fraud and waste from their organizations. -Dina (@HealthPayer)

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