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   Digital Forensics™ and Managed Healthcare
  With over $2 trillion in expenditures, healthcare is an industry that is ripe for fraud and abuse. When providers were being paid for procedures rendered, as in fee for service medicine, it was relatively easy to develop digital tools to spot excessive costs for procedures and unusually high prescribers of specialist services.
  But with maintenance of health becoming the focus, managed care is replacing fee for service, with providers being paid a fixed monthly premium amount, no matter what services are rendered. Premiums are calculated for cohorts consisting of people with various types and severity of diseases, thus making comparisons of premiums as meaningless as comparing apples and oranges. So it's been difficult to identify anomalous patterns of payments that are usually a sign of potential abuse.
  We have developed a patented Digital Forensics™ tool, CareMaps, that can, for the first time, compare premiums from prior years and from different geographical regions, so as to identify regions with the highest and lowest costs, as well as those with the best and the worst outcomes of various chronic disease treatments.
  Over 80% of Medicaid enrollees nationwide are on managed care contracts. Actuarial premium calculations use prior year's history of utilization and costs to arrive at a higher premium for next year presumably to account for the rise in medical needs and costs with the passage of time. In other words, there is no respite from the interminable annual rise in premiums. CareMaps is a powerful tool that will spot regions with anomalous rise in costs that could potentially signal fraud and abuse. The multi-year Medicaid analysis of New Mexico identified potential over-payments between 3% and 10% of the costs. Extrapolating this to the nation, the potential annual Medicaid savings will be between $18 and $60 billion.
Copyright 2006, 2011, 2019. Physmark, Inc. Corrales, NM.