Prevent Fraud Before Taking on Risk

Jean MacQuarrie, Vice President Payment Integrity Services, Truven Health Analytics, formerly the Healthcare Business of Thomson Reuters. As your organization prepares to take on risk, consider protection from fraud and abuse: there are over $700 Million in fraudulent healthcare claims annually. Section 6028 of the Affordable Care Act will require that all risk-bearing entities have a way to credential providers and re-credential or monitor them to limit fraud. Manual systems simply will not keep up and could increase staffing dramatically. Learn how to leverage multiple public record databases including death records, federal and multi-state sanctions, licensing boards, criminal records, credit records, and even utility records to verify that providers are legitimate and capable of providing care. Tools can present risk-bearing entities with an identification of the level of risk associated with specific providers so that onsite visits can be conducted efficiently and effectively. Included is an example of how a risk-bearing entity remains in control regarding what actions should take place with specific providers, and also supports the review of all providers, not only the select few.