A Verisk Health Company
CLINICALLY VALIDATED FRAUD, ABUSE AND OVERPAYMENT PREVENTION >
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What will the
Future hold?
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2013
by annual health care costs will surpass
$3 Trillion.
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Fraud
Losses from & will reach up to
Abuse $300 Billion.
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That’s a Loss of every day.
$820 Million
That’s a Loss of
$566 Thousand every minute.
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Clinically validated fraud, abuse and overpayment prevention >
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Stops here Fraud stops Now. fraud
Prevent Fraud | Improve Accuracy | Reduce Costs
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SAY HELLO TO
We provide private and public sector claims payors with a comprehensive suite of clinically validated fraud and abuse prevention services. Let us help you maximize claims accuracy and minimize payment waste.
Prevent Fraud | Improve Accuracy | Reduce Costs 10
Do You Have a Fraud
WE HAVE YOUR
Problem?
Solution.
www.hcinsight.com 11
our process
Works.
We have the tools to help you stop fraud, abuse and overpayment.
Prevent Fraud | Improve Accuracy | Reduce Costs 12
Robust
Advanced
25 MILLION MEMBERS >
OVER 3 MILLION ALGORITHMS >
1.3 MILLION PROVIDERS >
DYNAMIC CLAIM AND PROVIDER SCORING >
$90 BILLION PAID CLAIMS >
CUSTOMIZABLE RULES AND PARAMETERS >
450 MILLION CLAIM LINES >
REAL-TIME CLAIMS PROCESSING >
Clinical
Complete
MEDICAL CODING SPECIALISTS >
ACCOUNT SUPPORT TEAM >
CLINICAL INVESTIGATIVE UNIT (CIU) >
DEDICATED CLINICAL RESOURCES >
PHYSICIANS, NURSES AND DENTISTS >
AD HOC AND CUSTOM REPORTING >
NATIONAL CLINICAL PANEL >
APPEAL SUPPORT AND RESPONSE >
Data Warehouse
review
technology
service
www.hcinsight.com 13
CRA
Fraud, abuse & overpayment savings analysis for claims payors >
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Boost Your Bottom Line And We’ll Prove It Free We Can
Of Charge.
Identify Fraud | Expose Risk | Quantify Savings
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Let us quantify your annual fraud, abuse and overpayment savings and identify key areas of risk and waste.
“HCI has prevented the payment of over $5 million in inappropriate charges.” – Michael De Chellis Operating Engineers Trust Funds Inc.
Identify Fraud | Expose Risk | Quantify Savings 16
THE
THE
Problem
Solution
Fraud Stats 3% – 10% of the nation’s annual health care outlay is lost to fraud. By 2013, costs could eclipse $300 billion.
$311.1 $293.1 $277.0
(In Billions)
$262.4
$78.7 2010
$83.1 2011
$87.9 2012
$93.3
2013
Results > Measure PMPM savings projections > Align areas of risk with tailored solutions > Understand fraud and abuse program ROI Features > Comprehensive analysis on 24 months of data > Analysis by cutting-edge software systems > Identification of overpaid claims and dollars > Clinical review on a subset of suspect claims > Detection of questionable provider activity > Discovery of risk areas and vulnerabilities > Detailed web and hard-copy reporting > Analysis findings over 95% accurate > Results in just 4–6 weeks after receipt of data > Explanation and onsite presentation of findings
US health care fraud projections for 2010 – 2013 / 3 – 10% loss
10% Loss 3% Loss
Next Steps Contact us for a complimentary Cost Reduction Analysis. Call 1.877.619.5557 or email info@hcinsight.com today.
www.hcinsight.com 17
Fraud, abuse & overpayment prevention for professional health care claims >
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It Takes a
Clinical Expert to diagnose Fraud
Prevent Fraud | Improve Accuracy | Reduce Costs
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Maximize your claims payment accuracy, identify fraudulent providers and reduce your professional claims costs.
“We have experienced positive changes in provider billing habits resulting in significant savings.” – Mary Alice Garcia, BA, CPC Medicaid MCO
Prevent Fraud | Improve Accuracy | Reduce Costs 20
THE
THE
Problem
Solution
Fraud Stats 3% – 10% of US physician and clinical care outlay is lost to fraud. By 2013, losses could reach $63 billion.
$63.6 $60.4 $57.7
(In Billions)
$55.2
$16.6 2010
$17.3 2011
$18.1
2012
$19.1
2013
Results > Reduce expenditures up to $5 PMPM > Improve claims payment accuracy up to 10% > Increase annual profitability up to 5% Features > Prepayment analysis on 100% of professional claims > Clinical review on all suspect claims and providers > Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring > Highly customizable rules and parameters > Real-time claims processing and ad hoc reporting > Clinically-driven appeals support and response > Daily notification of suspect providers and claims > Easy to use web-based application > Total professional claims cost-containment solution
Fraud Projections for Physician & Clinical Services 2010 – 2013 / 3 – 10% Loss 10% Loss 3% Loss
Next Steps Contact us for a complimentary Cost Reduction Analysis. Call 1.877.619.5557 or email info@hcinsight.com today.
www.hcinsight.com 21
Fraud, abuse & overpayment services for dental claims >
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Dentists Drill into YOUR Claims.
LET OUR
Prevent Fraud | Improve Accuracy | Reduce Costs
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Optimize your claims payment accuracy, pin-point fraudulent providers and lower your dental claims costs.
“HCI clients have access to the most comprehensive code editing and profiling application ever developed in the dental payor industry.” – Dr. Jeff Davee HealthCare Insight®
Prevent Fraud | Improve Accuracy | Reduce Costs 24
THE
THE
Problem
Solution
Fraud Stats 3% – 10% of America’s dental care outlay is lost to fraud and abuse. By 2013, losses could approach $13 billion.
$12.1 $11.6 $11.1
(In Billions)
$10.6
$3.2 2010
$3.3 2011
$3.5
2012
$3.6
2013
Results > Reduce expenditures up to $4 PMPM > Improve claims payment accuracy up to 10% > Increase annual profitability up to 5% Features > Prepayment analysis on 100% of dental claims > Clinical review on all suspect claims and providers > Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring > Highly customizable rules and parameters > Real-time claims processing and ad hoc reporting > Clinically-driven appeals support and response > Daily notification of suspect providers and claims identified > AADC Certified Dental Consultant review and support > Full-service professional claims cost-containment solution
Fraud Projections for Dental Services 2010 – 2013 / 3 – 10% Loss
10% Loss 3% Loss
Next Steps Contact us for a complimentary Cost Reduction Analysis. Call 1.877.619.5557 or email info@hcinsight.com today.
www.hcinsight.com 25
Fraud, abuse and overpayment prevention for facility claims >
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Avoid Overpayment Trauma WITH OUR FACILITY BILL Experts.
Prevent Fraud | Improve Accuracy | Reduce Costs
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Elevate your claims payment accuracy, identify fraudulent providers and decrease your facility claims costs.
“HCI customers using this service consistently realize facility claim savings of 15% – 30%.” – Darin Johnson, MBA HealthCare Insight®
Prevent Fraud | Improve Accuracy | Reduce Costs 28
THE
THE
Problem
Solution
Fraud Stats 3% – 10% of the national outlay for facility claims is lost to fraud and abuse. By 2013, losses could exceed $99 billion.
$99.3 $93.2 $87.7
(In Billions)
$83.0
$24.9 2010
$26.3 2011
$28.0
2012
$29.8
2013
Results > Reduce expenditures up to $4 PMPM > Improve claims payment accuracy up to 10% > Decrease targeted claim costs up to 30% Features > Prepayment analysis on 100% of facility claims > Clinical review on all suspect claims and providers > Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring > Highly customizable rules and parameters > 24-hour turn-around after receipt of records > Signed settlement agreements to eliminate balance billing > DRG audit, validation and repricing services > Claims adjustment based on state and payor standards > Fee negotiation by highly trained professionals
Fraud Projections for Facility Claims 2010 – 2013 / 3 – 10% loss
10% Loss 3% Loss
Next Steps Contact us for a complimentary Cost Reduction Analysis. Call 1.877.619.5557 or email info@hcinsight.com today.
www.hcinsight.com 29
Fraud, abuse & overpayment prevention for pharmacy claims >
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Just the
right dose of pharmacy
Fraud Prevention
Prevent Fraud | Improve Accuracy | Reduce Costs
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PharmaClaim Strengthen your claims payment accuracy, isolate fraudulent providers and reduce your pharmacy claims costs.
“We have a responsibility to protect our client’s benefit dollars and HCI makes that easy for us.” – Renee Haas Employee Benefit Management Corp. (EBMC)
Prevent Fraud | Improve Accuracy | Reduce Costs 32
THE
THE
Problem
Solution
Fraud Stats 3% – 10% of US pharmacy claim outlay is lost to fraud. By 2013, losses could exceed $30 billion
$30.8 $28.9 $27.2
(In Billions)
$25.6
$7.7 2010
$8.1 2011
$8.7
2012
$9.2
2013
Results > Reduce rising pharmacy expenditures > Improve Rx claims payment accuracy > Increase annual profitability Features > Prepayment analysis on 100% of pharmacy claims > Clinical review on all suspect claims and providers > Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring > Highly customizable rules and parameters > Real-time claims processing and ad hoc reporting > Clinically-driven appeals support and response > Daily notification of suspect providers and claims identified > Easy to use web-based application > Full-service pharmacy claims cost-containment solution
Fraud Projections for Pharmacy Claims 2010 – 2013 / 3 – 10% loss
10% Loss 3% Loss
Next Steps Contact us for a complimentary Cost Reduction Analysis. Call 1.877.619.5557 or email info@hcinsight.com today.
www.hcinsight.com 33
Fraud, abuse & overpayment prevention for vision claims >
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Clinicians detect your payment blind spots. Let our
Prevent Fraud | Improve Accuracy | Reduce Costs
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Improve your claims payment accuracy, detect fraudulent providers and minimize your professional claims costs.
“HCI goes to bat for the client and the patient to be sure the provider is being fair and just.” – Orlo L. “Spike” Dietrich The Ansley Group
Prevent Fraud | Improve Accuracy | Reduce Costs 36
THE
THE
Problem
Solution
Fraud Stats 3% – 10% of America’s outlay for other health care services (including vision care) is lost to fraud and abuse.
$8.4 $8.0 $7.5
(In Billions)
$7.2
$2.1 2010
$2.3 2011
$2.4
2012
$2.5
2013
Results > Reduce annual claims expenditures > Improve vision claims payment accuracy > Increase overall profitability Features > Prepayment analysis on 100% of vision claims > Clinical review on all suspect claims and providers > Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring > Highly customizable rules and parameters > Real-time claims processing and ad hoc reporting > Clinically-driven appeals support and response > Daily notification of suspect providers and claims > Easy to use web-based application > Full-service vision claims cost-containment solution
Fraud Projections for Other Health Services 2010 – 2013 / 3 – 10% loss 10% Loss 3% Loss
Next Steps Contact us for a complimentary Cost Reduction Analysis. Call 1.877.619.5557 or email info@hcinsight.com today.
www.hcinsight.com 37
powered by Biologics, INC.
Improved patient outcomes, therapeutic analysis and cost management for oncology claims. >
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Therapeutic Solution for Rising Oncology Case Costs. Your
Elevate Care | Improve Satisfaction | Manage Costs
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powered by Biologics. INC.
Enhance patient care through improved outcomes, increase provider satisfaction and manage oncology claims costs.
“OncologyClaim Insight™ guarantees that the most appropriate plan of treatment is delivered and that patients receive the highest level of clinical support and care.” – Brian Smith HealthCare Insight®
Elevate Care | Improve Satisfaction | Manage Costs 40
THE
THE
Problem
Solution
Cancer Care Stats Cancer is a complex and costly disease. By 2013, cancer care costs could reach up to $130 billion annually.
$129.9 $122.3
$115.6
(In Billions)
$109.6
2010
2011
2012
2013
Results > Elevate patient care and outcomes > Increase provider satisfaction levels > Realize a tangible ROI of more than 8:1 Features > 100% of oncology cases reviewed for eligibility > Plan of treatment reviewed to ensure compliance with evidence-based guidelines and best practices > Oncology Certified Nurses (OCNs) guide patient care > Prompt and accurate claim reimbursement > Drugs and claims analyzed to prevent overbillings > Differentiated approach optimizes outcomes > Physician approval and detailed savings reports > Access to expert oncologist advisory panel > Powered by industry leader Biologics, Inc.
Cost Projections for Cancer Care 2010–2013 / 5% of personal health spend.
Next Steps Contact us for a complimentary Cost Reduction Analysis. Call 1.877.619.5557 or email info@hcinsight.com today.
www.hcinsight.com 41
Why you’ll
Like Us.
CLINICAL REVIEW BY MDs, RNs & DDS’ >
Detailed ad-hoc Reporting >
PREPAYMENT SaaS SOLUTION >
Appeals Support & Response >
TOTAL Payor CUSTOMIZATION >
IMMEDIATE REALIZATION OF ROI >
Real-Time Claims Processing >
Solutions for all Payor Types >
memberships & Accreditations
Prevent Fraud | Improve Accuracy | Reduce Costs 42
how to P
Phone
S
Connect With HCI
M
877.619.5557
F
Fax
801.285.5801
Twitter | Facebook YouTube | Linkedin
Contact Us. E
R
HCI Fraud Resources
info@hcinsight.com
W
Web
www.hcinsight.com
www.profilermag.com www.stophealthcarefraud.com
HealthCare Insight 10897 S. River Front Parkway Suite 200 South Jordan, UT 84095
© 2009 HealthCare Insight – A Verisk Health Company. HealthCare Insight, PhysicianClaim Insight, DentalClaim Insight, FacilityClaim Insight, PharmaClaim Insight VisionClaim Insight, Code Validator Pro and Fraud Finder Pro are registered service marks and trademarks of HealthCare Insight. All other product or corporate names are trademarks or registered trademarks of their respective companies. Fraud loss figures based on Centers for Medicare & Medicaid Services (CMS) spending projections and National Health Care Anti-Fraud Association (NHCAA) loss estimates.
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HealthCare Insight 10897 S. River Front Parkway Suite 200 South Jordan, UT 84095
Phone 877.619.5557 Email info@hcinsight.com Web www.hcinsight.com