Every payer can agree on one thing. There is fraud, waste, and abuse happening that they cannot see or see fast enough with the limitations of current claims data-centric technology stacks. One more technology in the stack doesn't solve the problem of not being able to see dynamic behaviors, relationships, and outliers that lead to over-payments on basic CMS edits as well as undetected complex fraud and collusion schemes. More claims data-centric technology is not the solution. Dynamic provider-centric risk detection technology coupled with continuously-credentialed provider integrity data is the solution for increased FWA detection and near real-time prevention. That's because stacks of claim data-centric technologies (even those using conventional artificial intelligence) will never see what providers are doing individually, in relationship with all other providers, and in relationship to all other claims on each-and-every claim submitted.
This session will focus on the benefits of a provider-centric FWA prevention approach powered by artificial intelligence that is dynamic and uses both supervised and unsupervised machine learning for detection beyond rules-based technologies. It will highlight strategies for FWA prevention at five points along the claims workflow including pre pre-payment, pre-payment, and post-payment positions. Fraud and SIU teams will be particularly interested in this combination of technologies to detect and automatically package fraud and collusion schemes you can’t see now or can’t see fast enough with the limitations of claim-centric approaches.
1. Understand the FWA detection limitations of claims data-centric approaches
2. Understand how a provider centric-approach such as Integr8 AI increases FWA detection and prevention
3. Understand the benefits of provider-centric FWA prevention pre pre-payment, pre-payment, and post-payment
Clay Wilemon
Clay serves as CEO at 4L Data Intelligence™. He has launched over 500 new healthcare brands and holds patents in artificial intelligence and medical technologies. Clay is on the Board of Directors at Octane, a Southern California non-profit economic development organization that has helped hundreds of technology and med-tech companies get started. He a graduate of Vanderbilt University.
Greg Lyon
Greg is a recognized anti-fraud expert with experience in Financial Services and Healthcare Payments that includes serving as Director of Fraud Prevention at United Healthcare. His guiding principle is, “The best way to fight fraud is to prevent it.” Greg is a graduate of Colgate University and is a Certified Financial Planner.
4L Data Intelligence
Website: https://4ldata.com/
4L Data Intelligence™ is leading the way in a new era of healthcare program and payment integrity using the patented power of Integr8 AI Risk Detection™ technology to find, fight and prevent FWA in near real-time. Integr8 AI™, coupled with our continuously credentialed provider database, creates a revolutionary provider-centric capability to dynamically detect FWA you cannot see with stacks of traditional claims data-centric editing and analytics solutions.
The 4L FWA Prevention™ solution rapidly detects and prevents FWA at five points across the claims management workflow including pre pre-payment, pre-payment and post-payment positions. At each point, patented Integr8 AI technology dynamically and continuously detects provider behaviors, relationships and outliers without the limitations of rules-based and claim data-centric solutions. In short, it enables you to see what providers are doing individually, in relationship with all other providers, and in relationship to all other claims on each-and-every claim submitted.
4L FWA Prevention pre-payment and post-payment detection and prevention results are continuously delivered in four complementary modules. These are:
- Provider Integrity Edits
- Adaptive Claims Edits
- Billing Behaviors Analysis
- Provider Schemes Analysis.
For SIU teams, the new 4L SIU Hub™ packages the expanded range of Integr8 AI powered FWA detection behaviors and schemes into easy to use views with comprehensive investigation and lead management tools. This new capability increases FWA detection, reduces complexity and increases speed-to-decision on lead triage and investigation. All so you can Find, Fight and Prevent FWA Fast™.
