CATEGORY: Data Mining and Visualization

REVIEWER: Robert Nowell, assistant director of program integrity for North Carolina's Department of Health and Human Services Division of Medical Assistance Program.

BACKGROUND: The Program Integrity Section within North Carolina's Department of Health and Human Services Division of Medical Assistance Program has the responsibility to ensure that Medicaid dollars are paid correctly, overpayments are recovered and the Medicaid recipients receive quality care. Processing nearly 40 million claims for 1.2 million Medicaid eligibles on an annual basis, North Carolina pays out close to $6 billion per year for healthcare services delivered by approximately 57,000 enrolled providers.

PLATFORMS: WebSPOTLIGHT and FraudSPOTLIGHT by Intelligent Technologies utilize an n-tier architecture in Windows NT/95/98 and standard UNIX platform environments.

PROBLEM SOLVED: Our task is to detect fraud, abuse and waste in North Carolina's Medicaid program. The two major functions of FraudSPOTLIGHT are to detect specific instances of fraud, abuse and waste at the claim level, and to identify likely suspects for auditing or investigation at the provider level. FraudSPOTLIGHT has a library of 300+ filters that identify specific inappropriate claim activity beyond the routine edit and audit process of our claim payment system. This results in an immediate ability to collect overpayments and educate providers in areas of abuse or waste. Further, a combination of other analytics, including advanced statistical tools and data mining technologies, are available for characterizing various aspects of provider billing practice. This allows us to prioritize which providers we will audit. WebSPOTLIGHT is the browser-based interface that gives our investigators access to the full range of data they need to effectively and efficiently analyze leads, including those generated by the filters and models of FraudSPOTLIGHT.

PRODUCT FUNCTIONALITY: Our base implementation of FraudSPOTLIGHT came with 24 filters and 3 models. WebSPOTLIGHT provides us with data visualization and drill-down/drill-across capabilities from detection summaries and reports, through provider and recipient profiles, all the way to claim details. Additionally, it gives us an easy interface to perform ad hoc queries that can answer specific questions we formulate as we navigate through the data. Over the next 12 to 24 months, new filters, models and graphic enhancements will be added to our base system to further support our efforts and keep up with the changing healthcare fraud schemes.

STRENGTHS: WebSPOTLIGHT gives us a focus on fraud detection and a view into our data warehouse that we previously could not get without requesting time-consuming custom reports. It is easy to use and gives our investigators access to information and data that lead directly to actionable results. Because it is browser-based, our investigators do not have to learn a complex data mining tool. Data navigation, statistical reports, detection results and drill-down details are available with just a few clicks of the mouse.

WEAKNESSES: Though WebSPOTLIGHT provides an intuitive and easy-to-use interface, it has not incorporated a full-featured ad hoc query tool. Additionally, the report formats for printing from the interface need to be improved.

SELECTION CRITERIA: We were looking for a company that already had an understanding of our complex healthcare environment, domain expertise and products that had proven successful in other Medicaid fraud detection environments. After comparing products from numerous vendors, we determined that WebSPOTLIGHT and FraudSPOTLIGHT provided the best value to enhance our fraud detection and overpayment recovery efforts.

DELIVERABLES: In addition to the current filter and model detection results, WebSPOTLIGHT provides numerous reports, including previous detection results, detection summary reports and provider summary reports. It also delivers various views and profiles for provider, recipient and pharmacy data, as well as claims and claims details. WebSPOTLIGHT provides the capability to export any of these reports for use in other desktop applications.

VENDOR SUPPORT: ITC is very responsive, and our operational system has become a true customer/vendor partnership. Its staff is always available via e-mail or phone during business hours. The best part of working with the staff is the genuine concern they have for solving our business problem.

DOCUMENTATION: WebSPOTLIGHT's browser-based user interface is extremely easy to understand. The training material and documentation provide sufficient information to enable even our novice users to quickly and successfully master the product.

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