nhcaa conference installing predictive modeling claims scoring technology november 18, 2010 1
TRANSCRIPT
1
NHCAA CONFERENCE
Installing Predictive Modeling Claims Scoring
Technology
November 18, 2010
2
Welcome to Highmark
Primary Offices in Pittsburgh & Camp Hill along with satellite offices throughout the USA
18,500 Employees 4.6 Million Health Care
Members 28 Million Members
Across all Products 2008 Revenues: $12
Billion
Strategic Initiative toCombat Health Care Fraud
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
RuleBased Detection
Referrals
Recovered orAverted Costs
Evaluation / Prioritization
Investigation
DataTools
People
DataTools
People
DataTools
People
DataTools
People
Data
People
DataTools
People
PredictiveModeling
FinancialRecovery
DataTools
People
PaymentPrevention
DataTools
People
Provider ClaimsReview
Phase I
Phase IIProvider 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 New job rating/job class Job performance measurements
– Establish effective workflow processes between evaluation team and existing departments
Fraud cases Abuse cases Policy changes System changes
– Define and implement an effective value realization/ROI process
PROJECT ORGANIZATION
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Executive Sponsor
Business Owner
Steering CommitteeBusiness Owner
Program ManagerProject Manager
Claims Processing VPEvaluation Team
Manager
Program Manager
Governance TeamAudit VP
Program ManagerEvaluation Team
Manager
Pre Payment TeamEvaluation Team
Information Services Group Project
Manager
Information Services Group Team
Information Services Group Resources only needed until data extracts are in place
IMPLEMENATION TIMELINE
7
Hourly Extract Implemented 09/09 Go Live for Testing 03/29/10Initial Steering Committee Meeting
6/9/10
Pre-payment process flow
8
Value Realization Term Definition
TERM DEFINITION
Identified Savings Monies 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 savings Dollars identified by Pre-Pay but cost prohibited to pursue.
Deny Button Savings Calculated 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 Savings Monies received from refunds, restitutions, settlement agreements, claim offsets, and claim denials.
9
Included in calculation of identified savings
Case Summary
Unique Highmark Cases Opened 100
Highmark Cases Opened affecting multiple providers
19
Total Highmark cases opened 259
Cases related to un-pursued savings 14
Events related to previously identified cases 2
Cases referred to other plans 5
10
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Pre Pay Case Trending
April
1 -
May
28
June Ju
ly
Augu
st
Sept
embe
r
Octob
er0
20406080
100120140
14 15 21 21 16 1525
15
42
127
23 18
Unique CasesTotal Cases
12
Pre Pay Claim Trending
April
1 -
May
28
(Tes
t Per
iod)
June Ju
ly
Augu
st
Sept
embe
r
Octob
er0
1,000
2,0001,192 1,219 1,133
1,6612,024
1,816
0 99 97 101 62 154
ReviewDenied
13
Net ROI per month:Identified savings divided by monthly
operational costs
April
1 -
May
28
(Tes
t Per
iod
June Ju
ly
Augu
st
Sept
embe
r
Octob
er
ROI to
date
0
4
8
12
Hit Rate
Claims reviewed 9,045
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
Test Period June July August September October0
1
2
3
4
5
6
7
8
9
16
Deny Button Hit Rate:Claims reviewed divided by claims
denied
June July August September October0
1
2
3
4
5
6
7
8
9
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Productivity Graph
Other
Pro
ject
sJu
ly
Augu
st
Sept
embe
r
Octob
er0
20
40
60
80
100
120
Days WorkedVacationSystem OutagesOther Projects
Opened case value by monthly operating costs (MOC)
62
3
10
53
Case $ value < 50% of MOC
Case $ value 50% - 100% of MOC
Case $ value 101% - 150% of MOC
Case $ value 151% - 200% of MOC
Case $ value > 200% of MOC
18CONCLUSION: The identified savings of approximately 22% (18 of 83) of cases opened exceed the operational costs for an entire month.