what’s new in 3 - fico® | fico decisions€¦ · what’s new in 3.2 a new model and new summary...

Insurance Fraud Manager User GroupFebruary 8-9, 2011San Diego, CA

What’s New in 3.2A New Model and New Summary ReportsA New Model and New Summary Reports

Andrea Allmon Ben FriesenAndrea AllmonFICO Product Management

Ben FriesenFICO Product Management

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

Agenda» Independent Diagnostic Testing Facility Model

» Search

» Summary Reports

» Provider

» Member

» Reporting

» Assistance

» Partner Features

© 2011 Fair Isaac Corporation. Confidential.2 © 2011 Fair Isaac Corporation. Confidential.2

Entity Scoring

Major Feature Description 3.0 3.1 3.2Entity Scoring

Rendering/Performing Provider (US) Pharmacy (US) Pharmacy (US) Dental (US & Netherlands) Independent Diagnostic Testing Facilities (US)

© 2011 Fair Isaac Corporation. Confidential.3

Independent Diagnostic Testing Facilities

The Independent Diagnostic Testing Facility (IDTF) Model is to capture and identify misuse of laboratory and other diagnostic

d d hi h f d b th t t f ilit Aprocedure codes which are performed by the test facility. An Independent Diagnostic Testing Facility is a fixed location or mobile entity that is independent of a hospital or physician's office, where di i b f d b li d ifi ddiagnostic tests must be performed by licensed, certified, non-physician personnel under the supervision of a physician.


Reason Codes

» Age Groups

» Age Groups by Diagnosis Groups

» Member Sharing (Annual)

» Member Sharing (15 Days)

» Age Groups by Diagnostic Procedure Groups

» Diagnosis Group Mix

» Members without Services after Diagnostic Procedure

» Members with Prior Services from» Diagnosis Group Mix

» Diagnostic Procedures

» Diagnostic Procedure Mix

» Members with Prior Services from Diagnostic Provider

» Members without Services Prior to Diagnostic Procedureg

» Diagnostic Procedure Upcoding

» Independent Diagnostic Testing F iliti M b Li t

Diagnostic Procedure

» Place of Service Group Mix

» Selected Diagnostic ProceduresFacilities Member List

» Members per Week

» Members per Month

g

» Selected Modifier Activity


» Members per Month

Search

Major Feature Description 3.0 3.1 3.2 Save Search Select Fields Count of Results Export Results


Search Count and Export


Exporting Searches


Investigative Case Management

Major Feature Description 3.0 3.1 3.2 Customizable Case Codes System messaging Activity Reminders/Tickler Functionality

A dit f l Audit-proof log Referral/Triage Status Track case assignments Track case sources Track investigative activities

Track case costs Track case costs Mass case reassignment Track case recoveries Ability to link cases Track case notes Ability to attach files to cases Ability to attach files to cases Ability to develop custom queues for entities under

investigation

Correspondence generation Entity Flagging SIRUS Identification Mass case creation

In-depth Summary Information Provider Statistics Provider Group Information Member Statistics

Pharmacy Statistics


Pharmacy Statistics

In-Depth Summary Information

1/1-12/31 1/1-3/31 4/1-6/30 7/1-7/31

Old Process

»Collect one year of data

»Wait three months to gather late claims

»Send to FICO for modeling

»Filter for providers with enough activity in Medical Claims

»Deploy results (as much as 19 months after the fact)

»Create “Model Summary Statistics” only for Medical


y yModel

In-Depth Summary Information

» New Process

1/1-12/31 2/1-1/31 3/1-2/28

»Data is scored monthly»Data is scored monthly

»Models are always current

St ti ti b d t t ( t b d l) St ti ti»Statistics are by data type (not by model). Statistics available no matter which models have been run

»Statistics are always current»Statistics are always current

»Architected for cross-data statistics (Medical/Pharmacy and soon Facilities)


(Medical/Pharmacy and soon Facilities)

»Architected to allow cross-data modeling

Summary Screens


Provider Summary Report


Improved Member Summary


Reporting Features

Major Feature Description 3.0 3.1 3.2Breadcrumbs

Investigative Reports Report By Reason Code

Management Reports Case Listing Case Details

Claim Line Case Status Claim Line Case Status

Queue Inventory Reports

Savings Reports both Paid and Allowed Dollars

Security/Audit ReportsU Li t User List

Billing Reports

General Report Features Improved Paging


User List


$0.025

$22,219.48$10,000


Assistance Features

Major Feature Description 3.0 3.1 3.2

On-Line Help


Security and Login Features

Major Feature Description 3.0 3.1 3.2 Role Based Security Forced Password Expiration and Format Single Sign On Single Sign On


Single Sign On

» Allows site deployed users to by-pass the log on screen and use their network authentication

» Allows partners to deploy in a shared portal environment


Partner Features

Major Feature Description 3.0 3.1 3.2 Private Labeling Multi-payor Medical Claims Model


Insurance Fraud Manager User GroupFebruary 8-9, 2011San Diego, CA

THANK YOU

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. 22

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