ISO MedSentry detects suspicious medical billing

By Andy Tolsma September 24, 2013

Property/casualty insurers have a new tool to accelerate the detection of suspicious medical billing activity — and take informed action. ISO MedSentryuses a combination of advanced analytics, superior technology, and expert clinicians to detect suspicious patterns in medical billing data.

With ISO MedSentry, you can:

  • discover pockets of fraud risk in your own medical billing data
  • prioritize exposure associated with specific medical providers
  • investigate suspicious activity and prevent payment of fraudulent bills
  • take decisive action against suspicious providers with a prosecution-ready case
  • improve your ability to process legitimate first-party medical bills quickly
  • avoid the logjam of false positives

How it works

ISO MedSentry uses predictive analytics, clinical conditions, and multivariate models to help property/casualty insurance carriers identify suspicious medical billing activity and investi­gate cases of likely fraud. ISO MedSentry reveals patterns of aberrant treatment and billing behaviors, including:

  • unbundling — procedures that should be billed as a global procedure but are broken down into their constituent elements for billing
  • mismatch of diagnosis to procedure — chiropractic manipulation of the lower spine in the case of a neck injury, for instance
  • template or boilerplate billing — every patient receives the same treatment modalities
  • provider specialty/diagnosis/procedure mismatches — for example, a psychiatrist providing physical therapy modalities
  • high time billing — a provider bills for numerous time-consuming procedures that exceed the number of hours that a provider might reasonably work in a day
  • and many more

A comprehensive software-as-a-service (SaaS) platform, ISO MedSentry employs an intelligent rules and analytic engine. The platform offers highly customizable rules and data feeds and an intuitive user experience. The combination of ease of use and SaaS environment accelerates implementation and the detection of anomalies.

The turnkey ISO MedSentry system lets carriers begin improving results immediately. Insurers send their medical billing data to ISO MedSentry, which then applies conditions against the data to detect aberrant billing behaviors by providers. Once the analytical tools have identified the suspect providers, the system refers the providers to ISO MedSentry clinical analysts. Those expert analysts review the case in microscopic detail, using other ISO and Verisk Health assets and external sources to ensure that the suspicions suggested by the analytics are accurate and defensible. The analysts also significantly reduce false positives — a nagging problem with tools supplied by competitors. And the analysts provide appropriate standards-of-practice documentation to support their findings.

Finally, the analysts place all the information they’ve obtained into the ISO MedSentry desktop, which supplies a wide variety of additional information about the suspect provider. The system makes all the information available to the insurer’s investigations unit for action.

To learn more or to request a full demo — including an analysis of your company’s data — send e-mail to info.claimsearch@iso.com