Fraud & Security Reducing Health Care FWA Losses – Find Your Focus
A key component of stopping fraud, waste and abuse is to focus on your most productive targets: Who or what should be the focus of your payment integrity program?
Tag Archives: Health Care
Fraud & Security How Pre-Payment Prevention Can Lower Health Care Losses
The most effective approach to pre-payment prevention of losses is to risk score your claims, post-adjudication, prior to payment, in production-strength software which uses xAI and machine learning.
Fraud & Security How AI and Machine Learning Can Fight Health Care Fraud
AI and machine learning have become popular concepts in payment integrity. But how can they help reduce your losses to health care fraud, waste and abuse?
Fraud & Security Who Should Be Responsible for Health Care Payment Integrity?
Given the negative impact of fraud, waste and abuse on health care, it’s in every payer’s interest to focus on these problems.
Fraud & Security Reducing Health Care Fraud, Waste & Abuse: How Much Is Enough?
So how does a health care payer measure success in payment integrity? How much is enough?
Risk & Compliance Using Analytics to Attack Opioid Abuse
Recently, congressional staff requested a briefing from FICO on how our analytics are tackling the opioid epidemic – an issue that, despite pervasive gridlock in Congress, has become a priority for both Democrats and Republicans. Our experts welcomed the opportunity to share their experiences. We believe that the increased use of analytics can play a pivotal role in confronting this challenge. Opioids are a class of drugs that include heroin as well as pain medications such as codeine, oxycodone and morphine. In 2014, according to the Centers for Disease Control, more than 28,000 people died from opioids – a number greater than the deaths from traffic accidents that same year. And the opioid problem is getting worse, with increasingly more deaths involving fentanyl and other synthetic opioids. The House and Senate recently approved a bill addressing the opioid crisis by nearly unanimous votes. Though both parties wanted additional provisions, the... [Read More]
Analytics & Optimization BEA on Event Driven Architecture Sounds a lot like EDM
(Posted by guest Blogger, Gib Bassett) Yesterday BEA Systems released a white paper summarizing their findings of a customer study regarding Business Process Management (BPM). The paper is titled “The State of the BPM Market – Business and IT: Solving Process Problems Together.” BEA also culled through numerous analyst and other industry expert insights to narrow in on the key trends driving adoption of BPM related technologies. There were two especially notable items in the report that show an Enterprise Decision Management (EDM) approach to operational decision automation, connection and improvement is becoming an increasingly mainstream concept – even if the term EDM isn’t the label. First, the report connects BPM to the growing trend toward Event Driven Architecture (EDA), a term applied by IDC in 2007 to describe an IT infrastructure blending: “Event Middleware and Complex Event Processing,” “Event-Enabled BPM Suite,” “Event-Enabled Process Modeling,” and “Business Analyst Skill Set.” The business driver for...
Analytics & Optimization EDM Helps Minimize Trade Offs Between Application Maintenance and Strategic Initiatives – So Says Forrester Research
(Posted by guest Blogger, Gib Bassett) While Enterprise Decision Management (EDM) is not called out specifically in Forrester Research’s January 28 report, “The State Of Enterprise Software Adoption: 2007 To 2008,” it describes issues top of mind among technology executives addressable with EDM technologies, such as Business Rules Management Systems (BRMSs). The report is based on results of a survey of 1,017 IT decision-makers in North American- and European-based enterprises. One of the principal values of BRMS is that they streamline application maintenance by simplifying the process of changing application logic while also enabling others outside the IT organization to become involved in that process (i.e. the business domain experts most often familiar with that logic). The net benefit to the IT organization is greater productivity while also being more responsive to organizational changes that typically cascades to applications. For this very reason, IT decision makers should evaluate a BRMS as part of their technology initiatives,...
Analytics & Optimization Gartner’s 2008 Predictions Include Bright Future for Enterprise Decision Management
(Posted by guest Blogger, Gib Bassett) Gartner recently issued two “Predicts: 2008” reports highlighting their expectations for Enterprise Architecture and the Business Process Management Suites (BPMS) Market. Both recognize noteworthy and highly complementary trends reflecting the value of Enterprise Decision Management (EDM), particularly Business Rules Management Systems (BRMSs) supporting EDM principles. In the most recent report, issued December 11, 2007, and titled “Business Process Management Alters Business and IT Collaboration,” Gartner predicts that “BPMS Subsumes the Business Rule Market,” primarily due to the fact a baseline rules engine is a required component within a BPMS:“Strategic Planning Assumption: By 2012, the BPMS technology market will subsume greater than 80% of the pure-play business rule technology sector (for example, stand-alone business rule engines).”Readers should not mistake this statement as implying the market for Business Rules Management Systems will be subsumed, which is not likely simply because a BRMS...
Analytics & Optimization The need for automated decisioning in healthcare
(Posted by guest blogger, James Taylor) Regular readers of the blog will know that I am fairly cynical about the power of electronic health records to be more than a building block for better healthcare. I do not believe that we will all get significantly better care simply because our doctors have access to an electronic record. So, for instance, when I saw this article A New Push for E-Health Records over on CRM daily I was disappointed once again. While the article discusses the importance of giving doctors an incentive to move to electronic records, it does not address the fundamental issue that an electronic record is only the beginning. Yes, as the doctor in the article notes, an electronic system allows them to treat patients even when not next to the paper files and that's a useful bonus. However, given the very real time and cost pressures on doctors, it is not obvious how much more value they might get out of it. Let's face it, how long does your doctor spend with you? How much time do they have to review your records (electronic or paper)? The...