CollaborationIs KeyTransforming the Fight Against Fraud Through Shared Data and Ideas

1November 7, 2013

Presented By

Karthik Balakrishnan, Ph.D.Sr. Vice President, Fraud Solutions and Analytics

2

Jeff YoungVice President, Fraud Control

About Verisk Analytics

Publicly-Traded

Focus on The Science of Risk

Financial Services

Property & Casualty

We drive performance in the business of healthcare. By combining clinical and analytics expertise with advanced technology and services, we help payers, employers and providers solve complex problems with measurable results.

$10.2B Market Cap

15.7% Annual Growth 2009-2011

Supply Chain

Healthcare

3

• $234B – Healthcare fraud & abuse

• A big problem becoming bigger

• Payer Siloes limit efficacy of FWA detection and prevention

• Many suspect schemes cannot be detected in a payer silo

• Cross-Payer Data Pooling• Challenging to do, but can offer tremendous new insights and

capabilities to further the fight against fraud

• Reality or just a concept?

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Pooled Data Background

• Specialty: Family Practice

• State:  Florida

• Payer A – billed $200K in the last 2 years• 3-8 hours of treatment per day

• Cross-Payer Exposure• Payer B – billed $360K in the last 2 years• Payer C – billed $520K in the last 2 years• Payer D – billed $270K in the last 2 years• ..

• < 10 hours a day for any one payer Only time-based codes

• Pooled data shows• 50% of all dates of service: 10.25 - 56.75 hours billed• 32% of all dates of service: 20 – 56.75 hours• 14% of all dates of service: 30 – 56.75 hours

• $2.6M – Exposure across payers in last 2 years • 70% - percent of days only one or two payers were billed

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Payer A

Payer B

Payer C

A provider billing for more than the number of hours in a dayThis scheme would be impossible to detect in a payer silo without cross-payer pooled data

The Man Who Defied Time

How Did We Get Here?

INDEX SYSTEM1930s

25 Million Queries

850 Million Claims

90% Participation

1 Unified PlatformClaimSearch1999

• 850 million claimsIndustry’s only comprehensive property & casualty claims database

• +90% participation Of the P&C industry (by DWP volume)

100% of the top 10

• +85,000 Active System Users

• 25 million Investigation Queries (IQ) performed annually

INDEX, PILR, MIB

2005FraudFinder Pro Released

2009AMD Conceived

2011AMD Launched

1076Providers Referred

70% of Auto carriers20% of Workers Comp carriers

Already Aggregated MedAware Alerts Issued 441

Clinics Identified694

In Identified Exposure$191M

NICB Successes

Plan Reporting Requirements

Case Tracker

DATA

ANALYTICS

ANALYTICS

SIU

Law Enforcement Data Provisioning

MEDICAL + RX DATA

Case Outcome Feedback

PA

YE

R

PA

YE

R

SIU

Cross Payer Advanced Analytics

ENTITY RESOLUTION

Cross Payer

Payer

Cross Payer

Suspect Providers

TOUCHHuman

Case Tracker

Suspect Provider Database

Feedback to Enhance Analytics

Suspect Entity Compliance Reporting

Cross-Payer Case Referral

Suspect Referrals

ID Theft

Alerts

Cross Payer Suspect Provider

Alerts

State MedicaidCMS

Collaboration

2012Alliance Initiated

2013Alliance Launched

Founding members include:

8 Million Lives

41 States

800K + Providers

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Healthcare Payers

Pooled Data Fraud Analytics

Collaboration Tools

The Alliance is Operational

WhatWe’re Finding

INDEX becomes Part of ISO1999Case

Study 1

Impossible Hours

Specialty: Orthopedic Spinal Surgeon

Location: Texas

Trigger: High Billing Hours

• Findings

• 11.25 Hours billed to plan A• 11.25 Hours billed to plan B• 22.50 Total hours/daily (not accounting for pre- and post-service time)

$1,004,524Billed in Previous 12 Months

Date of Service

Tim

e in

Hou

rs

Avg.

INDEX becomes Part of ISO1999Case

Study 2

Provider Alert

Specialty: Cardiology

Location: Texas

Trigger: Excessive Cardiovascular Studies

• Findings

• Most patients have no prior history• Few receive follow-up care• Patients have same diagnosis• Split bills

$1,168,859Billed in Previous 12 Months

INDEX becomes Part of ISO1999Case

Study 3

Impossible Patients

Specialty: Immunology

Location: Texas

Trigger: High Billing Hours

• Findings

• High billing time across partners• 32.7 Average patients per day• 99th percentile in Z score

• $3,718,784 Billed in Previous 12 Months

WhereWe’re Going

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Expand States

• Currently live in 12 states

Deploy New Cross-Payer Schemes

• Collusion analytics• Medical ID theft

Extend to Rx and Dental Data

Include P&C in Alliance

Next Steps

See You at NHCAA’s Annual Training Conference Booth #101

Thank You Questions?

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Contact us: webinars@veriskhealth.com

www.veriskhealth.com