A 2021 4L Data Intelligence analysis of over four (4) million workers compensation claims paid showed that 19,612 providers out of a network of 86,000 submitted fraudulent claims totaling about 10% of all claims paid during the prior year. This study was conducted retrospectively using 2020 claims and network provider data for a regional workers compensation payer that paid about $107 million in fraudulent, wasteful or abusive claims on approximately $1.17 billion in total payments.
4L Data Intelligence deployed our Provider Intelligence & Integrity and FWA Prevention & Recovery solutions to retrospectively evaluate the integrity of previously paid claims, provide automated support data for recovery and increase real-time, pre-adjudication FWA prevention on future claims. Each of the 4L Data Intelligence solutions used in this analysis are powered by our patented Integr8 AI technology platform.
The findings in this regional workers’ compensation study were similar to other analyses performed with the patented Integr8 AI technology platform. Most of the FWA activity identified retrospectively could have been detected and prevented in real-time using 4L Data Intelligence solutions on a continuous basis.
FWA Prevention Step 1:
Identify High-Integrity Providers Upfront & Continuously
The first set of preventable FWA findings in this analysis were related to the provider network itself. Almost 23 percent (22.8%) of providers were flagged for some level of FWA activity. Twenty-two (22) providers were practicing with OIG, SAM or other health sanctions and should not have been in this or any other provider network. Numerous providers were practicing with multiple tax ID numbers and hundreds of others had problematic collusion maps noting high-risk relationships with DME providers, pharmacies, or other healthcare professionals. All of these providers could have been identified upfront and eliminated from the network before they were able to commit fraudulent, wasteful, or abusive actions with our Provider Intelligence & Integrity solution insights around providers’ demographics, status, relationships, and behaviors. And this same solution performs continuous integrity monitoring to identify providers with integrity risks on a daily basis.
FWA Prevention Step 2:
Detect ‘Red Flag’ Behavioral And Transactional Risks Before Payment Occurs
The second set of preventable FWA findings center around coding and other detectable and preventable behavioral ‘red flag’ anomalies. Common findings included: 1) suspicious drug prescriptions with specific CPT codes, 2) outlier procedures associated with a particular ICD code or provider type and 3) procedures billed outside of evidence-based guidelines. All of these FWA-related anomalies and more are detectable and preventable in real time with Integr8 AI continuous surveillance that enables literally every claim to be audited against millions of complex combinations of CPT and ICD-10 codes and payer guidelines as well as against individual and collective provider behaviors and relationships.
FWA Prevention Step 3:
Quickly Recover FWA Claims Already Paid
The 4L Data Intelligence FWA Prevention & Recovery solution used in this analysis, proved to provide immediate and detailed intelligence for quantifying and documenting FWA activity by provider. Think of it as an FWA case file at the press-of-a-button.
This enables recovery efforts to begin quickly and equips program integrity units and collectors with deep provider-specific data to align recovery efforts as closely as possible with the action, creating a very favorable scenario for collection.
FWA Prevention Step 4:
Make Targeted Changes To Mitigate Future FWA Risk
This analysis demonstrated a number of macro-actions that the payer could take to mitigate future FWA risk. These steps included: 1) extract rendering provider information from PDF images, 2) manage invalid or missing data problems by back-walking based on known attributes, 3) improving the plan design and 4) improving formulary design.
FWA Prevention Step 5:
Establish Real Time Detection & Prevention To Save Big Dollars
The workers compensation payer study demonstrated that detecting and preventing FWA claims real-time BEFORE the claims are paid, can literally save payers millions of dollars each year in the of over-payment and collection costs.
It also proved that the 4L Data Intelligence Provider Intelligence & Integrity solution and the FWA Prevention & Recovery solution are powerful tools for recovering FWA over-payments, but also in detecting and preventing the cost, time, and manpower burden of recovering fraudulent payments.
To schedule a free Provider Integrity Scan or a FWA Prevention data scan, contact info@4LData.com
