Aggregated Medical Database

Prosecutorial
Administrative Actions
• Successful criminal prosecution
• Court-ordered restitution
• Sanctions by professional certification boards
• Indictments
• Warrants
• Arrests
1
Medical Fraud
1,000
909
900
804
800
700
562
600
500
474
400
300
200
100
0
2007
2008
2009
Medical Related PAAs
2010
2
2010 Medical Fraud Trends
• Questionable Claim Referrals Indicate:
– 40% of the total Casualty Referral Reasons are
allegations of wrongdoing by the medical provider
• Duplicate Billing
• Excessive Treatment
• Provider/ Facility Improperly Licensed
• Billing for Services Not Rendered
• Solicitation
• Inflated Billing
• Unbundling/ Upcoding
3
Aggregated Medical Database
Overview:
• Top data analytic priority identified in
the Integrated Business Plan
• Goal is to aggregate and analyze
medical billing data to identify suspect
providers
• BOG approved NICB proposal to engage
Health Care Insight in developing the AMD
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Aggregated Medical Database
• Enhance NICB’s ability to combat medical
provider fraud
- Increase access to industry data that is non-existent
today
- Identify medical providers perpetrating fraud across
P&C industry
- Prioritize investigations of suspect providers
- Publish MedAWARESM Alerts specific to findings to
participating members
- Increase prosecution of fraudulent medical providers
5
Aggregated Medical Database
• Memorandum of Understanding
• Twenty carriers signed MOU
Step 1
• Carrier Data On-Boarding
• Multiple carriers in various states of readiness
Step 2
• Auto and Workers’ Compensation data represented
• Analysis and Analytics Applied
• Target to focus on applicable edits & conditions
Step 3
• Development of customized conditions
• Clinical Review
• Reduce false positives
Step 4
• ”The Human Touch”
• Results
• Provides referrals for NICB analysis
• MedAWARESM Alerts to participating carriers
Step 5
• 1st Alerts were posted on April 19, 2011
6
MedAWARESM Alerts
MedAWARESM Alerts
are posted on the
Members-Only Web
Site and are viewable
only to participating
members.
7
8
Commercial Fraud
• Specialized Equipment
• Cargo Theft
• Slip and Fall Rings
9