2015 Annual Training Conference & Anti-Fraud Expo

NCCI Edit Development: Integrating Data Analysis, Clinical Information, Payment Policy and Claims Processing (Room Seaport B)

18 Nov 15
11:00 AM - 12:00 PM

Tracks: Management Path, Transformation of Health Care

Speaker(s): Daniel Duvall, MD, Chief Medical Officer, Center for Program Integrity, Deputy Center Director, Center for Program Integrity, U.S. Department of Health and Human Services, CMS

This lecture will present an overview of the use of automated edits as tools in the prevention of fraud, waste and abuse. Using lessons learned from the NCCI maintenance and development processes, we will examine a framework for the integration of the four critical knowledge areas of edit development. We will discuss the uses and limitations of data analysis and medical review, the evaluation of rules that depend on both clinical standards and statute and regulation (or commercial contract and payer policy), and the constraints created by the claims processing systems. We will end with a brief discussion of technical considerations in edit implementation.