Dark Reading is part of the Informa Tech Division of Informa PLC

This site is operated by a business or businesses owned by Informa PLC and all copyright resides with them.Informa PLC's registered office is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 8860726.

Risk

11/16/2011
01:59 PM
50%
50%

Verizon Uses Predictive Modeling To Detect Health Fraud

Verizon software can spot doctors prescribing excessive amounts of medication and other trends that indicate falsified billings.

12 Innovative Mobile Healthcare Apps
(click image for larger view)
Slideshow: 12 Innovative Mobile Healthcare Apps
The telecommunication giant has just unveiled a new software platform called Verizon Fraud Management for Healthcare, a fraud detection system tailored to the healthcare industry. It uses predictive modeling technology to examine unusual patterns and trends in incoming healthcare payment requests.

The platform is designed to send potentially fraudulent claims information to case managers for investigation before payments are made. Such a system, Verizon officials say, will help mitigate the administrative and legal costs involved when health organizations pay the claim and then go after the fraudsters, which usually involves hefty legal fees and other costs associated with a recovery operation.

According to Connie Schweyen, managing principal, Verizon Connected Healthcare Solutions, the system is geared toward spotting, for example, doctors prescribing excessive amounts of medication, the unusual use of patient identification numbers to order large amounts of medical equipment, and other trends that indicate falsified billings, or show that orders were not delivered or were medically unnecessary.

"The software can detect all of those things by using the algorithms within the system," Schweyen told InformationWeek Healthcare. "The software then scores those incidents and prioritizes the various kinds of cases and medical data to ensure that they are working on the highest-cost, most-at-risk cases first."

[ Today's mobile devices have transformed medical care in unprecedented ways. For an in-depth look at exactly how clinicians are using these tools, tune into the InformationWeek Healthcare Webcast The Mobile Point of Care: Making the Right Choices]

In addition to detecting fraud, waste, and abuse in healthcare claims payment systems, the technology also offers customers the ability to:

-- Create faster responses to address potential risks.

-- Provide strategic insight into systemic issues to drive improvements or make necessary policy changes.

-- Generate executive-level management reports to measure results and determine return on investment.

The Centers for Medicare & Medicaid Services (CMS) already has begun using Verizon's fraud management platform as part of a Northrop Grumman-led team to detect fraud and waste in CMS' Medicare Program.

The technology, which CMS started using in July, is a customized version of the software platform Verizon uses for its own fraud detection programs. CMS uses the software to examine incoming Medicare program claims and routes those that might be fraudulent to case managers for investigation.

According to the latest statistics from the U.S. Department of Health and Human Services, in 2009, national health expenditures totaled $2.5 trillion representing 17.6% of the U.S. gross domestic product. Of that number, fraud accounted for as much as $260 billion, or at least 10% of annual U.S. healthcare expenses.

The Verizon platform is available immediately and the company is targeting the software to customers at federal and state health programs as well as commercial health insurers.

"The current post-paid model used for healthcare fraud programs is highly inefficient and unsustainable," Nancy Fabozzi, Frost & Sullivan's senior industry analyst covering healthcare information technology, said in a statement. "Verizon's use of advanced software technology to evaluate and process medical claims prior to payment is indicative of the future direction of healthcare fraud prevention."

 

Recommended Reading:

Comment  | 
Print  | 
More Insights
Comments
Newest First  |  Oldest First  |  Threaded View
Lisa Henderson
50%
50%
Lisa Henderson,
User Rank: Apprentice
11/17/2011 | 2:24:58 AM
re: Verizon Uses Predictive Modeling To Detect Health Fraud
Predictive modeling is used in many industries, but this is a very useful case study of how fraud protection works. I wonder in what other areas in healthcare could this be applied? I don't know, but good article.

Lisa Henderson, InformationWeek Healthcare, contributing editor
COVID-19: Latest Security News & Commentary
Dark Reading Staff 7/6/2020
Russian Cyber Gang 'Cosmic Lynx' Focuses on Email Fraud
Kelly Sheridan, Staff Editor, Dark Reading,  7/7/2020
Lessons from COVID-19 Cyberattacks: Where Do We Go Next?
Derek Manky, Chief of Security Insights and Global Threat Alliances, FortiGuard Labs,  7/2/2020
Register for Dark Reading Newsletters
White Papers
Video
Cartoon
Current Issue
Special Report: Computing's New Normal, a Dark Reading Perspective
This special report examines how IT security organizations have adapted to the "new normal" of computing and what the long-term effects will be. Read it and get a unique set of perspectives on issues ranging from new threats & vulnerabilities as a result of remote working to how enterprise security strategy will be affected long term.
Flash Poll
The Threat from the Internetand What Your Organization Can Do About It
The Threat from the Internetand What Your Organization Can Do About It
This report describes some of the latest attacks and threats emanating from the Internet, as well as advice and tips on how your organization can mitigate those threats before they affect your business. Download it today!
Twitter Feed
Dark Reading - Bug Report
Bug Report
Enterprise Vulnerabilities
From DHS/US-CERT's National Vulnerability Database
CVE-2020-3931
PUBLISHED: 2020-07-08
Buffer overflow exists in Geovision Door Access Control device family, an unauthenticated remote attacker can execute arbitrary command.
CVE-2020-15600
PUBLISHED: 2020-07-07
An issue was discovered in CMSUno before 1.6.1. uno.php allows CSRF to change the admin password.
CVE-2020-15599
PUBLISHED: 2020-07-07
Victor CMS through 2019-02-28 allows XSS via the register.php user_firstname or user_lastname field.
CVE-2020-8916
PUBLISHED: 2020-07-07
A memory leak in Openthread's wpantund versions up to commit 0e5d1601febb869f583e944785e5685c6c747be7, when used in an environment where wpanctl is directly interfacing with the control driver (eg: debug environments) can allow an attacker to crash the service (DoS). We recommend updating, or to res...
CVE-2020-12821
PUBLISHED: 2020-07-07
Gossipsub 1.0 does not properly resist invalid message spam, such as an eclipse attack or a sybil attack.