Health insurer’s ghostbusters take on ‘phantom providers’
New medical entities have made their way to
It's all an elaborate fraud scheme designed to get insurance companies to pay out on these false claims.
"It predominantly was in
The company has been employing data analytics to catch fraud as early as possible, Falduto added.
"You want to catch it very' early, instead of letting it continue for months or years when the money loss has become significant," he said. "The objective is to have a whole bunch of small cases, not a few large ones."
in the case of phantom providers, Falduto's team was even able to prevent any losses.
"Because of our analytics, we caught those (phantom providers) early," he said. "Usually they1 re a big hit, but we were actually able to identify the activity and prevent the money from actually going out the door."
According to Horizon, its Special Investigations Unit generated
That's because, by employing analytics, Falduto and his team are able to closely' monitor activity as it comes through the company's systems.
"1 like to use the image of a heart monitor, but I'm on the opposite: I'm looking for the up-and-down blip as opposed to the flat line," he said. "I prefer to see the line flat, but w'hen I see it blip up, that's an indicator that we need to quickly take a look and see what happened to cause that."
To achieve this, Horizon has hired a team that specializes in these digital skills.
"The focus today is really on the data analytics, and we utilize folks with strong programming backgrounds and marry them with our certified coders we have on staff, and put those two together to start mining the data," Falduto said.
First, the company establishes a "baseline" to create an image of what "the norm" looks like, Falduto said.
"Obviously, you look for outliers," he said. "And then an outlier doesn't mean you have a fraudulent situation. It could have a logical explanation as to why that that particular provider's practice is a little different than everybody else."
More specifically, the company builds models of ways it knows the sy'stem can be compromised.
"We do a lot of research both locally and nationally how schemes are perpetrated and then build analytic models to find that behavior happening here in Horizon," he said.
The data is than married with the investigative arm to track down the leads provided by the analytics.
"They will take the information from the analytics team, go hit the pavement and approve or disapprove what it might be saying," he said. "I will never conclude that there's fraud from looking at a data report. There's too many factors that go into making that type of determination, which is why the investigative arm of my organization is so critical."
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