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.

(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.
[ Todays 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 Verizons 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 & Sullivans senior industry analyst covering healthcare information technology, said in a statement. Verizons use of advanced software technology to evaluate and process medical claims prior to payment is indicative of the future direction of healthcare fraud prevention.

Last News
▸ Report from White House on Healthcare Exchanges Security. ◂ Discovered: 05/01/2025 Category: security	▸ Senator suggests cybersecurity norms ◂ Discovered: 05/01/2025 Category: security	▸ Gawker Media Sites Hacked, 1.3 Million Passwords at Risk ◂ Discovered: 05/01/2025 Category: security

**Cyber Security Categories**
Google Dorks Database	Exploits Vulnerability	Exploit Shellcodes

CVE List

Tools/Apps

News/Aarticles

Phishing Database

Deepfake Detection

Trends/Statistics & Live Infos

Tags:
Verizon Uses Predictive Modeling To Detect Health Fraud