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Confidential. This presentation is provided for the recipient only and cannot be reproduced or shared without Fair Isaac Corporation's express consent.

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Presentation on theme: "Confidential. This presentation is provided for the recipient only and cannot be reproduced or shared without Fair Isaac Corporation's express consent."— Presentation transcript:

1 Confidential. This presentation is provided for the recipient only and cannot be reproduced or shared without Fair Isaac Corporation's express consent. © 2011 Fair Isaac Corporation. 1 Insurance Fraud Manager User Group February 8-9, 2011 San Diego, CA Independent Diagnostic Testing Facility (IDTF) Model Supriti Singh Senior Scientist FICO February 8, 2011

2 © 2011 Fair Isaac Corporation. Confidential. 2 2 Agenda » What are IDTF’s » Motivation for IDTF Model » Identification of IDTF providers » Overview of the Model »Fraud Schemes and Variable Design »IFM Screen Shots

3 © 2011 Fair Isaac Corporation. Confidential. 3 What are IDTF’s »Definition: An independent diagnostic testing facility (IDTF) is an entity independent of a hospital or physician’s office in which licensed or certified non-physician personnel (technicians) perform diagnostic tests under physician supervision

4 © 2011 Fair Isaac Corporation. Confidential. 4 Motivation »Model originally developed in conjunction with Texas Medicaid »Texas payments to IDTFs had increased from $10M to $82M in 2004, roughly an 800% increase in over 5 years. »OIG found that from 1995 to 2005, expenditures for advanced imaging paid under the Medicare Physician Fee Schedule grew more than fourfold, from $1.4M to $6M. »Services provided by IDTF’s accounted for nearly 30% of this growth. OIG work has found problems with IDTFs, including noncompliance with Medicare requirements and billing for services that were not reasonable and necessary. » From 2000 through 2006, Medicare spending for physician imaging services doubled from $7B to $14B—an average annual increase of 13%, compared to an 8% increase in spending for all Medicare physician-billed services over the same time period (GAO Report)

5 © 2011 Fair Isaac Corporation. Confidential. 5 Motivation »IDTF tests may have been billed for beneficiaries who have had the same services billed by multiple providers, often within days, a month or several months »Medicare and private health insurers pay up to $16B a year for needless imaging tests ordered by doctors. (American College of Radiology, 2004) »CMS addressed improper billing and potentially fraudulent claims submitted by IDTFs operating in California. This special project resulted in $163M in denied charges and the termination of Medicare billing privileges for 83 IDTF providers.

6 © 2011 Fair Isaac Corporation. Confidential. 6 Identification of IDTF Providers »Reasonable amount of activity in certain Procedure Codes »Abuse of procedure codes typically used for diagnostic testing »Specific areas of abuse » Radiology codes (70000) » Gastroenterology (91000 -91299) » Ophthalmology (92002 -92499) » Otorhinolaryngologic Services(92502-92700) » Cardiography (excl. therapeutic services (93000-93799) » Non-invasive vascular studies (93875-93990) » Pulmonary(94010-94799) » Immunology (95004-95199) » Neurology and Neuromuscular Studies (sleep testing) (95805-96004) » Neuro-Cognitive Mental/Speech testing (96100-96117) » Additional HCPCS

7 © 2011 Fair Isaac Corporation. Confidential. 7 Identification of IDTF Providers »Procedure code examples: » 71010 (Radiology Chest) » 71020 (Radiology Chest 2 views) » 93010 (Electrocardiogram interpretation & report only) » G0130 (Single Energy X-Ray Bone Density study) » Total number of claim lines in the greater than threshold » Atleast 500 medical claim lines for a provider to qualify as an IDTF provider » Currently no provider type or specialty restrictions » Medical Claims data used as input

8 © 2011 Fair Isaac Corporation. Confidential. 8 Overview of the IDTF Model »Each provider is given a single score based on analysis on 1 year’s worth of historical data. »This data is summarized to generate a rich profile that provides a holistic characterization of each providers activity »This profile includes variables capturing procedure code and procedure group utilization, patient utilization patterns, patient and provider patient profiles etc. »The providers are rank-ordered, via an unsupervised model, based on how unusual their activity profile is compared to their peers »Reason-codes are provided that indicate what aspect of a given provider’s activity are deemed most suspicious

9 © 2011 Fair Isaac Corporation. Confidential. 9 IDTF Model (Overview) »Fraud Schemes »Excessive advanced imaging services billed for children (highest allowed dollar) 1. MRI brain scans 2. CT of facial area »Excessive billing with unusual diagnoses for children » E.g. non-specific headaches for babies »Variable Design »Activity breakdown in dollars, claim lines, # member percentages » Combination Age/Diagnosis groups » Combination Age/Procedure groups » Age groups -21 groups » Procedure Groups - 34 groups » Diagnosis Groups - 20 groups » Place Of Service groups

10 © 2011 Fair Isaac Corporation. Confidential. 10 IDTF Model (Overview) »Fraud Scheme: Procedure Upcoding »E.g. Billing for more expensive imaging code »Variable Design »Create groups of procedure codes » Manual grouping of procedure codes in range » E.g. 70544, 70545 (Magnetic Resonance Angiography without/with contrast) »Dynamically compute average paid amount for each procedure code »Identify providers with higher/lower utilization of a code in the procedure group »Reason Code: DIAGNOSTIC PROCEDURE UPCODING

11 © 2011 Fair Isaac Corporation. Confidential. 11 IDTF Model (Overview) »Fraud Scheme: Sleep code abuse »Billing on separate days for duplicate service » two night PSG (Polysomnogram) with CPAP Titration » split night PSG with CPAP Titration »95810 & 95811 »Potential refinement: Add more procedure codes specified by our customer »Variable Design »Procedure concentration for high utilization of specified procedure codes » SELECTED DIAGNOSTIC PROCEDURES » 95810 & 95811 »Procedure concentration for high utilization of other procedure codes » DIAGNOSTIC PROCEDURES

12 © 2011 Fair Isaac Corporation. Confidential. 12 IDTF Model (Overview) »Fraud Scheme »Overuse of modifier 59 (Distinct Procedural Service) to bypass edits »Overuse of modifiers » 76 (Repeat Procedure) » LT, RT, 91 (Repeat diagnostic lab test) »Potential refinement: Add modifiers specified by our customers »Variable Design »Compute concentrations and flag suspects which have high utilization of each modifier mentioned above »Reason code : SELECTED MODIFIER ACTIVITY

13 © 2011 Fair Isaac Corporation. Confidential. 13 IDTF Model (Overview) »Fraud Scheme: »IDTF Member Sharing (networking among IDTFs) »Sharing patient lists »Variable Design: »Identify providers sharing a high number of patients with other IDTFs »If a pair of facilities shares more patients than would be expected, they will score high on commonality score » Through out the 12 month period –MEMBER SHARING »The temporality commonality score is calculated based on patient sharing within a 15 day window » Within 15 days –MEMBER SHARING 15 DAYS

14 © 2011 Fair Isaac Corporation. Confidential. 14 IDTF Model (Overview) » Through out the 12 month period –MEMBER SHARING » Within 15 days –MEMBER SHARING 15 DAYS Example: IDTF Networking providers for an IDTF X420 and Providers ABC 500 patients Networking provider Members for Network provider Members shared annually CommonalityCommonality Score Temporal Commonality Temporal Commonality Score A123500750.22090.1200 B4565001500.78500.4450 C7895002250.939890.7987

15 © 2011 Fair Isaac Corporation. Confidential. 15 IDTF Model (Overview) »Fraud Scheme »Billing possibly unnecessary services »Billing without proper pre or post care »Variable Design »Identify providers with a high occurrence of patients without » pre-visits » MEMBERS WITHOUT SERVICES PRIOR TO DIAGNOSTIC PROCEDURE » post-visits » MEMBERS WITHOUT SERVICES AFTER DIAGNOSTIC PROCEDURE »Identify providers with a high occurrence of self-referrals » with referring provider given the procedure code » MEMBERS WITH PRIOR SERVICES FROM DIAGNOSTIC PROVIDER

16 © 2011 Fair Isaac Corporation. Confidential. 16 IDTF Model (Overview) »Other variables »High utilization per member in dollars or claim lines in a » Day (e.g. MEMBERS PER DAY DOLLARS) » Week (e.g. MEMBER PER WEEK CLAIM LINES) » Month (e.g. MEMBER PER MONTH DOLLARS)

17 © 2011 Fair Isaac Corporation. Confidential. 17 IFM Screen Shots

18 © 2011 Fair Isaac Corporation. Confidential. 18 IFM Screen Shots

19 © 2011 Fair Isaac Corporation. Confidential. 19 IFM Screen Shots

20 © 2011 Fair Isaac Corporation. Confidential. 20 IFM Screen Shots

21 © 2011 Fair Isaac Corporation. Confidential. 21 IFM Screen Shots

22 © 2011 Fair Isaac Corporation. Confidential. 22 © 2011 Fair Isaac Corporation. Confidential. 22 IDTF Discussion Peer Groups Additional fraud schemes Additional Procedure Codes/Modifiers

23 Confidential. This presentation is provided for the recipient only and cannot be reproduced or shared without Fair Isaac Corporation's express consent. © 2011 Fair Isaac Corporation. 23 Insurance Fraud Manager User Group February 8-9, 2011 San Diego, CA THANK YOU Feb 8, 2011 Supriti Singh Senior Scientist supritisingh@fico.com

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