Expanding Beyond Facility RAC Audits with Adaptive Predictive Analytics
(Room Balboa A-C)
18 Nov 15
3:25 PM
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4:25 PM
Tracks:
Anti-Fraud Technology Solution
Determining the optimal program integrity strategy for facility claims is an ongoing challenge for most healthcare payer organizations. The complexity of inpatient and outpatient facility claims coupled with complicated medical policy compliance makes the review process demanding, labor-intensive, arduous, and slow. Many payers and government entities depend on recovery audit contractors (RAC) to perform a majority of their fraud investigations for facilities. Many of the RAC issues are covered by well-defined local coverage determination (LCD) or national coverage determination (NCD), which identify specific combinations, procedures, drugs, and/or diagnoses. While this is proven to be effective, there's still more money on the table being lost because of new systemic problems that go undiscovered. While thousands of rules/concepts by Recovery Audit Contractors (RACs) can ferret out specific fraud, waste and abuse issues, only adaptive predictive analytics can identify hidden egregious errors, and discover new and emerging problems. Learn how a comprehensive program integrity strategy can help address complex facility claims.