The efficient and accurate identification and validation of fraud, waste, and abuse within healthcare is a complex undertaking. After all, the diagnostics and treatment interventions applied in a pre-term delivery performed by high-risk obstetrics specialists and a team of NICU providers within an inner-city academic hospital can vary greatly from those utilized in a routine, rural delivery by a family practitioner in a local medical center of 40 overnight beds.

Factors such as care delivery venue type, provider type, payor type, medical condition, diagnostic approach, intervention, geography, and time play an intricate role differentiating appropriate claim and cost variances from fraud, waste, and abuse. Despite this being the case, however, most healthcare organizations are unable to analyze adequate breadth and depth of these data sets to achieve the appropriate signal detection power necessary to efficiently achieve this critical differentiation. Their perspective is understandably limited – restricted by the realities of their provider, facility, and member scope and access to advanced analytics required to perform appropriate comparative considerations across billions of events on a daily basis. A broader view and a more advanced analytical infrastructure changes the game.

MedAssurant has healthcare data insight into the practice of medicine and delivery of healthcare in more than 99% of the counties throughout the U.S. The billions of medical events and millions of validating EMR and paper-based medical record reviews have served to empower a Claims Integrity™ analysis system of unique capability.

From the direct financial improvements of fraud, waste, and abuse resolution, to the many additional benefits of data accuracy improvement such as risk adjustment, outcome measurement scores, and disease management, the achievement of superior Claims Integrity™ brings significant advantage to today’s healthcare organizations.