Solution

Our distinctive approach for combatting

Fraud, Waste, and Abuse (FWA) combines informatics,

clinical expertise, forensics, information technology

and advanced data visualization

FraudLens is the First near Real-Time Healthcare Fraud Detection and Prevention Software Solution.

FraudLens (FL) is a one-of-a-kind software solution that enables healthcare payers to finally make a huge impact on fraud, waste, and abuse (FWA) by moving from a “pay and chase” and “manual review” model to an automated “detect and prevent” model. FL’s complete solution that includes a near real-time FWA detection system and a Provider Relationship Platform (PRM), after many years of research and development, is specifically designed to address the financial burden caused by pre-payment of high volume, low dollar FWA as well as the low volume, high dollar FWA that exist within the healthcare industry today. It is estimated that 90% of all FWA is low dollar claims that are not being addressed today.

FraudLens’ sophisticated near real-time FWA detection system is developed through a combination of the following attributes:

  • Clinical Knowledge
  • Informatics
  • Forensics
  • Information Technology
  • Advanced Data Visualization

Using this unique combination, FL has developed a multi-vectored (multiple angles/scenarios/algorithms) approach that reviews all claims from all providers within hours and detects and provides the exact details of Who, What, When, Where, and How FWA is committed. This unique multi-vectored approach is administered pre-payment and pre-adjudication saving the healthcare payer millions of dollars.

The FraudLens FWA findings (reports) are then fed real-time into FL’s innovated Provider Relationship Management platform. The PRM is used to achieve a behavioral change in the providers through communication, education and incentives used to entice the provider to stop submitting questionable claims. PRM tracks the FWA over time, identifies any changes in provider behavior and triggers an escalation of communication between the Provider and Payer. The end result is that FraudLens provides a complete solution that changes the current “pay and chase” and “manual review” model to an automated “detect and prevent” model.

Despite years of effort and a multitude of variations of the “pay and chase” model, the percentage of success as reported by the Office of the Inspector General (OIG) of Health and Human Services for 2013 was less than 6% of the total estimated healthcare fraud.

When the “pay and chase” results of 2013 are compared to the entirety of FWA, the success rates drop to a dismal 0.6%. This methodology requires the use of highly trained, expensive professionals using very powerful yet difficult-to-use software to process the mountains of data that are needed to meet the evidentiary requirements to make the “pay and chase” model effective. Thus it is impractical to use “pay and chase” to deal with any small dollar FWA.

To truly make an impact against FWA, the system must take a look at all claims before the provider is paid. FraudLens supplements the “pay and chase” model with a more proactive approach that attacks the problem of small dollar FWA as well as large dollar FWA at the onset. FraudLens identifies the FWA early (near real-time) before it gets out of control when the FWA is still small amount of money. Stop FWA payments at this stage and small problems never get a chance to grow into large ones. FraudLens was designed to detect FWA early which allows early intervention with the provider. This is the essence of the FraudLens proven “detect and prevent” solution.

Healthcare data is both an abstraction and a representation of a real event. We at FraudLens understand this and together with clinical experts, are able to reconstruct this event.

FraudLens applies its Multi-Vectored technology (multiple smart and connected algorithms) on all claims data flagging the suspicious claims within hours with the exact details of who has committed FWA, what was fraudulent, when it the FWA happened, where it happened and how it happened. The results are then organized into a visual display dashboard that is easy to understand and easy to use.

Once the FWA data has been collected, our clients can then use our innovative and first-of-its-kind Provider Relationship Management platform to help manage the suspicious claims and questionable providers who tried to defraud them by offering the provider an opportunity to address the issue by resubmitting appropriate claims, where necessary. Our solution also identifies the good providers, who can be incentivized to continue their non-fraudulent claims. Last but not least, for those providers that do not address the issues of FWA that FraudLens has determined problematic and continue to defraud the payer, the FraudLens PRM platform will provide enough evidence to support legal action, as payers deem appropriate and necessary.

FraudLens includes multiple detection algorithms to detect and prevent the biggest fraud, waste, and abuse schemes.

FraudLens is a customizable system that detects and prevents fraud waste and abuse occurring in provider claims.

We also understand that there may be challenges specific to your organization that are not adequately addressed by our included algorithms. In such cases, we are able to modify an existing algorithm or develop an entirely new algorithm to focus on your particular concerns and plug this into our existing FraudLens near real-time FWA detection system.

Thus you retain all the existing benefits of FraudLens PLUS receive the added benefit of our customized plug and play algorithm.