Managing fraud and abuse

The impacts of unwarranted payments stemming from potentially fraudulent, wasteful or abusive billing affect your entire organization: lost benefit dollars, unproductive recovery efforts and added resources to manage and complete administrative work.

InvestiClaim™, a module of McKesson Total Payment™, allows payers to stop more wasteful and abusive claims pre-pay than ever before and recover fraudulent claims more efficiently. The module leverages the Total Payment claims auditing rules engine and claims operational data store, so you can smoothly and effectively combine clinical rules and data-driven analytics.

InvestiClaim delivers expert fraud, waste and abuse detection as well as analytic and case management tools via a convenient, easy-to-use Web-based model. The solution identifies aberrances and trends in the claim data using a sophisticated scoring methodology that elevates and highlights the most probable cases before they are paid or quickly after they are paid. With clear identification of suspect claims, health plans can significantly reduce “false positive” leads and focus resources on critical investigations.

Benefits

• Improves detection.  InvestiClaim identifies scenarios of unwarranted billing at the front of the claim workflow and displays predictive scores for aberrance via the Web so users can quickly take action on high scoring encounters.
• Optimizes payment policies. Systemic weakness reports identify wasteful or abusive practices that can be prevented by creating new rules with the flexible Total Payment rules engine.
• Builds effective, defendable cases. Electronic case management tools built into InvestiClaim help consolidate and manage evidential data and investigation activities to build solid, defensible cases.
• Streamlines and automates investigations. The system makes it easy to log and track daily events, case notes and status. With accurate, timely records, investigators can easily compile and share information to streamline work administration.
• Facilitates cross-department collaboration. Extensive workflow functionality enables full collaboration among special investigations, claims operations and provider auditing departments.
  
• Documents savings.  InvestiClaim helps users identify and document saved benefit dollars stemming from unwarranted claim submissions.

Do you want to know more about InvestiClaim or our Total Payment solution? Call us at 800.782.1334 or request more information.