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NHCAA CONFERENCE Installing Predictive Modeling Claims Scoring Technology November 18, 2010 1.

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Presentation on theme: "NHCAA CONFERENCE Installing Predictive Modeling Claims Scoring Technology November 18, 2010 1."— Presentation transcript:

1 NHCAA CONFERENCE Installing Predictive Modeling Claims Scoring Technology November 18,

2 Welcome to Highmark Primary Offices in Pittsburgh & Camp Hill along with satellite offices throughout the USA Primary Offices in Pittsburgh & Camp Hill along with satellite offices throughout the USA 18,500 Employees 18,500 Employees 4.6 Million Health Care Members 4.6 Million Health Care Members 28 Million Members Across all Products 28 Million Members Across all Products 2008 Revenues: $12 Billion 2008 Revenues: $12 Billion 2

3 Strategic Initiative to Combat Health Care Fraud Three Phase Approach Three Phase Approach –Enhance query capabilities of existing claims history repositories. –Purchase a provider scoring model which allows for automated detection of aberrant provider behavior. –Purchase an automated claims scoring model which scores suspicious claims prior to payment. 3

4 Fraud Detection and Investigation Process Flow 4 RuleBased Detection Referrals Recovered or Averted Costs Evaluation / Prioritization Investigation Data Tools People Data Tools People Data Tools People Data Tools People Data People Data Tools People Predictive Modeling Financial Recovery Data Tools People Payment Prevention Data Tools People Provider Claims Review Phase I Phase II Provider Scoring Model Phase III - Predictive Modeling Claims Scoring Model Tools

5 Implementing Pre-Payment Claims Scoring Technology Critical Success Factors: –Efficient data transmission of claims (post adjudication but prior to physical payment). –Building an effective evaluation team: Appropriate skill sets Appropriate skill sets New job rating/job class New job rating/job class Job performance measurements Job performance measurements –Establish effective workflow processes between evaluation team and existing departments Fraud cases Fraud cases Abuse cases Abuse cases Policy changes Policy changes System changes System changes –Define and implement an effective value realization/ROI process 5

6 PROJECT ORGANIZATION 6 Executive Sponsor Business Owner Steering Committee Business Owner Program Manager Project Manager Claims Processing VP Evaluation Team Manager Program Manager Governance Team Audit VP Program Manager Evaluation Team Manager Pre Payment Team Evaluation Team Information Services Group Project Manager Information Services Group Team Information Services Group Resources only needed until data extracts are in place

7 IMPLEMENATION TIMELINE 7 Hourly Extract Implemented 09/09 Model Construction and Data Gathering 09/09 – 03/26/10 Go Live for Testing 03/29/10 Implement IFM Pre- Payment Software 5/25/10 Initial Steering Committee Meeting 6/9/10 Year-end value realization and ROI statistics due to Steering Committee and Project Sponsor 12/31/10

8 Pre-payment process flow 8

9 Value Realization Term Definition TERMDEFINITION Identified SavingsMonies identified from suspicious providers, contracting, system edits or medical policy issues identified by the FICO pre-payment software. Calculations for ROI are 12 months. Un-pursued savingsDollars identified by Pre-Pay but cost prohibited to pursue. Deny Button SavingsCalculated each time a team member denies claim payment. Previously Identified Savings Dollars identified by the software in which an active case is already addressing the issue. Savings referred to other plans Dollars identified by Pre-pay but the case has been transferred to another plan (IBC, NEPA, etc.) Actual SavingsMonies received from refunds, restitutions, settlement agreements, claim offsets, and claim denials. 9 Included in calculation of identified savings

10 Case Summary Unique Highmark Cases Opened100 Highmark Cases Opened affecting multiple providers19 Total Highmark cases opened259 Cases related to un-pursued savings 14 Events related to previously identified cases 2 Cases referred to other plans 5 10

11 Pre Pay Case Trending 11

12 Pre Pay Claim Trending 12

13 Net ROI per month: Identified savings divided by monthly operational costs 13

14 Hit Rate Claims reviewed9,045 Highmark Cases opened 259 Case hit rate 2.9% Deny button hit 513 Deny button hit rate 5.7% 14

15 Case hit rate: Claims reviewed divided by cases created 15

16 Deny Button Hit Rate: Claims reviewed divided by claims denied 16

17 Productivity Graph 17

18 Opened case value by monthly operating costs (MOC) 18 CONCLUSION: The identified savings of approximately 22% (18 of 83) of cases opened exceed the operational costs for an entire month.


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