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FICO® Insurance Fraud Manager User Group :. San Diego, CA | May 7--8, 2014 . How To Get The Most Out Of IFM. Eileen Guiney, CFE Senior Consultant Global Insurance – IFM FICO. Organization Overview - Getting Started Setting Up the Team Workload Assignment Establishing Queues

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how to get the most out of ifm

FICO® Insurance Fraud Manager User Group:

San Diego, CA | May 7--8, 2014

How To Get The Most Out Of IFM

Eileen Guiney, CFE

Senior Consultant

Global Insurance – IFM


Organization Overview - Getting Started
  • Setting Up the Team
  • Workload Assignment
  • Establishing Queues
  • Helpful Hints
organization overview getting started
Organization Overview – Getting Started
  • How to organize your team to get the most out of IFM
    • Setting up your teams
      • Claim Review
      • Medical Model
      • Pharmacy Model
    • Work load Assignment
      • Medical Model
      • Pharmacy Model
    • Establishing queues
      • Claim Review
    • Developing work flows
setting up the team
Setting Up the Team
  • Having the right staff in the right position makes all the difference. The proper training and qualifications will ensure that claims and providers will be reviewed or triaged correctly and efficiently.
    • Claim Review
      • Claims Reviewers
      • Nurse Reviewers
      • Coders
    • Medical Model
      • Data Analyst
      • Investigator
workload assignments
Workload Assignments
  • Like claim review, medical and pharmacy model results can be assigned to ensure greater efficiencies, increased job satisfaction and the highest possible ROI. Like the claim queues, medical and pharmacy model suspects can be sorted and assigned by:
    • Provider Specialty
    • Provider Score
    • Dollars Paid
establishing the queues
Establishing the Queues
  • How you set up the claims queues is very important to the overall success of the team, some examples include:
    • Analytic
    • Provider Specialty
    • Procedure Code
  • Specialized or focused queues lead to greater efficiencies, increased job satisfaction and ensures claims are reviewed and adjudicated properly
  • Setting up the queues properly is time well spent
helpful hints what has worked for me
Helpful Hints – What Has Worked For Me
  • Medical Suspect Model
    • Review the names of the suspects, do you recognize any of the suspects?
    • Compare the data driven specialty to the declared specialty (reclassification filter = yes).
      • Are they close or vastly different, could be an indicator of a problem or may just be a clerical error.
    • How many members does the suspect treat
      • Does it make sense given the specialty?
      • Review the medical members list – lots of useful information here.
      • Review the age and sex of the members, does it make sense.
      • Identify members with the highest claim volume and $’s paid.
    • How many procedure codes does this provider bill, drilling down will identify all the codes billed and the % as well as the $’s. Do the procedure codes make sense give the specialty, are only high $ codes billed?
helpful hints
Helpful Hints
  • Provider Reports – Once you have selected a provider that interests you, from the provider summary screen drill into the provider reports and review things like:
    • Activity Breakdown – questions to ask yourself
      • Has the providers income increased or decreased significantly – typically established providers incomes generally don’t change significantly from one year to the next, if it does you need to find out why.
      • Is this provider treating more patients than last year – again patient counts for established providers remain stable, significant increases or decreases could be indicative of a problem
      • Does this provider treat more women than men – often is specialty related but not always.
helpful hints1
Helpful Hints
  • What is the typical age of the patients being treated, does it make sense give the providers specialty
    • Example: I reviewed a chiropractor who treated both male and female patients which is perfectly normal but the age of the patients seemed a little odd, ranging from infants to 65 years old. Further review indicated that many of the members were part of the same family, again not an unusual practice. I kept digging because in many instances chiropractic care is a limited benefit and in my experience some providers will bill family members when the member being treated reaches their maximum benefit. This is something to always keep in mind when you are reviewing limited benefit providers.
helpful hints2
Helpful Hints
  • Percent of dollars
    • Identifies how much is paid out monthly, by diagnosis group, procedure group and age and gender. Questions to ask yourself: are the monthly payment somewhat consistent, if no why not. Does the provider practice in an area that has a lot of seasonal residents or do claims submissions spike to meet a providers expenses, many of us have seen the example of the doctor whose claims spike to cover tuition payment. Does this provider favor certain procedure codes, does he always bill the highest level E&M or does he think he might avoid detection if he always bills the mid level code.
helpful hints3
Helpful Hints
  • Top Days
    • Is this provider billing more services that could be done in a day
    • Does he have other providers working for him, ? Banned or excluded providers
    • Keep in mind the data you are looking at is just yours and most providers bill multiple payors, so this is really just a part of this daily activity.
    • Reach out to other payors
  • Top Members
    • Is this provider seeing some patients much more frequently than others, it may be appropriate given the patients diagnosis or it could be something else
      • When I was a client, my team identified a provider who was seeing a group of patients more frequently than most. He was writing scripts at each visit that the patients were filling and sharing with him, he was also paying each member a kickback, they received a % of what was paid for each office visit.
helpful hints4
Helpful Hints
  • Vendors Affiliated
    • Identifies providers affiliated with a particular tax ID
    • If one member of a group is billing inappropriately chances are other are too
helpful hints what has worked for me1
Helpful Hints – What Has Worked For Me
  • Systemic Patterns – very quickly identifies
    • High scoring procedure codes
    • High scoring analytic
    • Rendering providers
  • Allows for the easy identification of procedure codes and providers that warrant further review, development of medical policies and payment edits
  • Shows management where there money is going, are you bleeding or hemorrhaging benefit dollars for a particular procedure code or group of procedure codes
thank you

FICO® Insurance Fraud Manager User Group:

San Diego, CA | May 7--8, 2014

Thank You

Eileen Guiney,

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