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Insurance Fraud Manager User GroupFebruary 8-9, 2011San Diego, CA
What’s New in 3.2A New Model and New Summary ReportsA New Model and New Summary Reports
Andrea Allmon Ben FriesenAndrea AllmonFICO Product Management
Ben FriesenFICO Product Management
Confidential. This presentation is provided for the recipient only and cannot be reproduced or shared without Fair Isaac Corporation's express consent.© 2011 Fair Isaac Corporation. 1
Agenda» Independent Diagnostic Testing Facility Model
» Search
» Summary Reports
» Provider
» Member
» Reporting
» Assistance
» Partner Features
© 2011 Fair Isaac Corporation. Confidential.2 © 2011 Fair Isaac Corporation. Confidential.2
Entity Scoring
Major Feature Description 3.0 3.1 3.2Entity Scoring
Rendering/Performing Provider (US) Pharmacy (US) Pharmacy (US) Dental (US & Netherlands) Independent Diagnostic Testing Facilities (US)
© 2011 Fair Isaac Corporation. Confidential.3
Independent Diagnostic Testing Facilities
The Independent Diagnostic Testing Facility (IDTF) Model is to capture and identify misuse of laboratory and other diagnostic
d d hi h f d b th t t f ilit Aprocedure codes which are performed by the test facility. An Independent Diagnostic Testing Facility is a fixed location or mobile entity that is independent of a hospital or physician's office, where di i b f d b li d ifi ddiagnostic tests must be performed by licensed, certified, non-physician personnel under the supervision of a physician.
© 2011 Fair Isaac Corporation. Confidential.4
Reason Codes
» Age Groups
» Age Groups by Diagnosis Groups
» Member Sharing (Annual)
» Member Sharing (15 Days)
» Age Groups by Diagnostic Procedure Groups
» Diagnosis Group Mix
» Members without Services after Diagnostic Procedure
» Members with Prior Services from» Diagnosis Group Mix
» Diagnostic Procedures
» Diagnostic Procedure Mix
» Members with Prior Services from Diagnostic Provider
» Members without Services Prior to Diagnostic Procedureg
» Diagnostic Procedure Upcoding
» Independent Diagnostic Testing F iliti M b Li t
Diagnostic Procedure
» Place of Service Group Mix
» Selected Diagnostic ProceduresFacilities Member List
» Members per Week
» Members per Month
g
» Selected Modifier Activity
© 2011 Fair Isaac Corporation. Confidential.5
» Members per Month
Search
Major Feature Description 3.0 3.1 3.2 Save Search Select Fields Count of Results Export Results
© 2011 Fair Isaac Corporation. Confidential.6
Investigative Case Management
Major Feature Description 3.0 3.1 3.2 Customizable Case Codes System messaging Activity Reminders/Tickler Functionality
A dit f l Audit-proof log Referral/Triage Status Track case assignments Track case sources Track investigative activities
Track case costs Track case costs Mass case reassignment Track case recoveries Ability to link cases Track case notes Ability to attach files to cases Ability to attach files to cases Ability to develop custom queues for entities under
investigation
Correspondence generation Entity Flagging SIRUS Identification Mass case creation
In-depth Summary Information Provider Statistics Provider Group Information Member Statistics
Pharmacy Statistics
© 2011 Fair Isaac Corporation. Confidential.9
Pharmacy Statistics
In-Depth Summary Information
1/1-12/31 1/1-3/31 4/1-6/30 7/1-7/31
Old Process
»Collect one year of data
»Wait three months to gather late claims
»Send to FICO for modeling
»Filter for providers with enough activity in Medical Claims
»Deploy results (as much as 19 months after the fact)
»Create “Model Summary Statistics” only for Medical
© 2011 Fair Isaac Corporation. Confidential.10
y yModel
In-Depth Summary Information
» New Process
1/1-12/31 2/1-1/31 3/1-2/28
»Data is scored monthly»Data is scored monthly
»Models are always current
St ti ti b d t t ( t b d l) St ti ti»Statistics are by data type (not by model). Statistics available no matter which models have been run
»Statistics are always current»Statistics are always current
»Architected for cross-data statistics (Medical/Pharmacy and soon Facilities)
© 2011 Fair Isaac Corporation. Confidential.11
(Medical/Pharmacy and soon Facilities)
»Architected to allow cross-data modeling
Reporting Features
Major Feature Description 3.0 3.1 3.2Breadcrumbs
Investigative Reports Report By Reason Code
Management Reports Case Listing Case Details
Claim Line Case Status Claim Line Case Status
Queue Inventory Reports
Savings Reports both Paid and Allowed Dollars
Security/Audit ReportsU Li t User List
Billing Reports
General Report Features Improved Paging
© 2011 Fair Isaac Corporation. Confidential.15
Assistance Features
Major Feature Description 3.0 3.1 3.2
On-Line Help
© 2011 Fair Isaac Corporation. Confidential.18
Security and Login Features
Major Feature Description 3.0 3.1 3.2 Role Based Security Forced Password Expiration and Format Single Sign On Single Sign On
© 2011 Fair Isaac Corporation. Confidential.19
Single Sign On
» Allows site deployed users to by-pass the log on screen and use their network authentication
» Allows partners to deploy in a shared portal environment
© 2011 Fair Isaac Corporation. Confidential.20
Partner Features
Major Feature Description 3.0 3.1 3.2 Private Labeling Multi-payor Medical Claims Model
© 2011 Fair Isaac Corporation. Confidential.21
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