Medical Provider Fraud detection statistics

The Medical Provider Fraud detection analyzes data from medical claims to identify possible suspicious activity. Statistics are generated for a single provider and for a defined peer group for that provider.

Data Requirements for the Provider Fraud Models

The following table shows the default run schedules, the mandatory and optional statistics that are needed for the data models to provide useful information in the Pattern Explorer page and to create investigations automatically.

Table 1. title
Data Element Suspicious Count Excess Monetary Charged Excess Monetary paid Unusual Time Span Benford Manipulated Charge Benford Distribution Change Potential Anomaly Group Provider Patient Network Provider/Peer Time Profile RFM Analysis Unbundling Association Entity Analysis Folio Analysis Party Event Loss Analysis Peer Creation
Run Schedule Daily Daily Daily Weekly Monthly Monthly Weekly Monthly Monthly Weekly Monthly Daily Daily    
Provider Data
Specialty/Subspecialty M M M M - - M - M M - M M - -
Provider GID M M M M M M M M M M M M M - -
Provider Address (Street, ZIP) D-D D-D D-D D - - D - D D - M - - -
Invoice Data
Patient GID D D D D - - - M - - - - - MA -
Invoice GID D D D - - - - - - - - - - - -
Vendor Source D D D - - - D - - - - - - - -
Billing Timestamp - - - MA - - - - - - - - - - -
Paid Amount - - M - - - MA M - - - - - - -
Diagnosis D-D D-D D-D D-W - - D-W - D D-W M - - - -
Diagnosis Group D-D D-D D D - - D - D - - - - - -
Procedure Data (Line)
Rendering Provider GID M M M M M M M M M M M M M - -
Procedure without Modifier D-D D-D D-D D - - D-W - D-M D-W M - - - M
Procedure with Modifier D-D D-D D D - - D - D D -- - - - -
Procedure Group D-D D-D D-D D - - D - D D - - - - M
Place of Service D-D D-D D D - - D - D D - - - - -
Procedure Timestamp M D-D D-D MA M M M M - M M - - - M
Charged Amount - M - - M M MA M - M - - - - M
Units - - - - - - - - - - - - - - -
Loss Event
Loss Event GID - - - - - - - - - - - - - M -
Loss Event Timestamp - - - MA - - - - - - - - - M --
Policy Holder GID - - - - - - - - - - - - - MA -
Lawyer GID - - - - - - - - - - - - - MA -
Table Legend:
M

Mandatory. This analysis element is required.

MA

Mandatory Alternative. At least one MA analysis from the same column must be run.

D

Dimensional analysis.

D-D
Daily scheduled dimensional analysis.
D-M
Monthly scheduled dimensional analysis.
D-W
Weekly scheduled dimensional analysis.

Statistics for a Single Provider

The statistical computations for each provider and the data group are shown in the following table.

Table 2. Statistic Calculations for a Single Provider
Provider All Patient Claim Diagnosis Diagnosis Group Procedure without Modifier Procedure with Modifier Procedure Group Modifier
Provider Yes - - - - - - - -
Patients Yes - - Yes - Yes Yes - Yes
Invoice / Claim Yes Yes - Yes Yes Yes Yes Yes Yes
Diagnosis Yes Yes - - - - - Yes -
Diagnosis Group Yes Yes - - Yes - - - -
Procedure without Modifier Yes Yes - Yes - - - - Yes
Procedure with Modifier Yes Yes - Yes - - - - Yes
Prescriptions Yes Yes - Yes Yes Yes Yes Yes Yes
Place of Service Yes Yes - Yes Yes Yes Yes Yes Yes
Time of Service (Time of Day Span) Yes Yes - Yes Yes Yes Yes Yes Yes
Day of Service (Monday-Sunday) Yes Yes - Yes Yes Yes Yes Yes Yes
Soft Configured Dimension Yes Yes Yes Yes Yes Yes Yes Yes Yes

Statistics for a Peer Group

The statistical computations provide the average, count, maximum, minimum, sum, standard deviation (stdev), median, first quartile, and third quartile values for the peer group for a single provider as shown in the following table. A peer group can be providers in a geographic region, providers in a specialty, or other defined peer grouping.

Table 3. Statistic Calculations for a Peer Group
Dimension Average Count Min Max Sum Standard Deviation Median First Quartile Third Quartile
Visits Yes Yes Yes Yes Yes Yes Yes Yes Yes
Number of Unique   Yes - - Yes - - - -
Daily Visit Count Yes Yes Yes Yes Yes Yes Yes Yes Yes
Charged Amount Yes - Yes Yes Yes Yes Yes Yes Yes
Eligible Amount, Paid Amount Yes - Yes Yes Yes Yes Yes Yes Yes
Time Between Visits Yes - Yes Yes - Yes Yes Yes Yes
Composite Number of Dimensions by Dimension Yes - Yes Yes - Yes Yes Yes Yes