PDM Fraud & Abuse Solutions Introduction In addition to its significant internal expertise in the core areas of I.T. and anti-fraud operations, PDM has developed partnerships with industry leaders in the areas of fraud detection software, litigation support, and overpayment collections. With flexible a la carte and package solutions, PDM has solutions to meet all of your anti-fraud needs. The Problem The healthcare payment system continues to bleed and Fraud & Abuse is a leading cause of the problem. Industry experts estimate that 3%-5% of health care costs are fraudulent or abusive. The Cause The industry is especially susceptible to Fraud & Abuse. This is due to the large volume of claim transactions coupled with the shrinking amount of time states allow for payment. Other factors include: The measure of trust the public (and government) places in the providers of healthcare; The complexity of delivery system; and, Provider reimbursements that fail to keep up with the cost of living. The Result The bottom line is that inappropriate payments are made. In light of today’s 15%-20% premium increases, your customers demand effective program safeguards. In addition, federal health programs, as well as many states, have recognized the need for strong anti-fraud controls within the health insurance industry, and have mandated that those controls be put into place. The Solution Plan Data Management recognizes that fighting fraud not only helps the bottom line (nationally anti-fraud efforts generate a 7:1 ROI) it also sends a very effective message to your customers. PDM now products and services designed to detect, recover, and prevent overpayments as a result of fraud & abuse. These solutions are also designed to meet anti-fraud regulatory requirements many states have or expect to have in the near future. PDM offers a comprehensive suite of antifraud services. Specifically, PDM Fraud & Abuse Solutions can provide its clients: Fraud & abuse detection services through proactive data mining and analytics, Prospective (pre-payment) investigation of suspect claims, Retrospective (post-payment) fraud & abuse investigations, Resolution of fraud and abuse issues, including (but not limited to): Recovery of overpayments through demand, negotiated settlements, offsets, civil litigation, and support of criminal prosecution. Provider education aimed at preventing future inappropriate billings. Coordination with network management to ensure a sound provider network. Consulting services, including: Development of enterprise-wide anti-fraud controls. Compliance services, including: development of anti-fraud plans, fraud procedure manuals, mandatory reporting and annual report submission; Web-based anti-fraud awareness training for plan personnel; Anti-fraud awareness programs including web-based fraud alert and referral portals. For more information, contact Robert McGinley. Copyright © 2005 Plan Data Management, Inc. All rights reserved.