CLEVELAND, Feb. 4 2005 – LAWFUEL – The Law News Network – Armed with new anti-fraud software, the Financial Investigations department of Medical Mutual of Ohio recovered more than $4.5 million in fraudulent or erroneous claims in 2004.
“This is a huge step in trying to keep a lid on rising healthcare costs,”
said Brien Shanahan, director of Legal Affairs for Medical Mutual. “There are
many reasons for the rising cost of healthcare. We owe it to our customers to
limit the impact of fraud as much as possible.”
Combined with figures for 2003, Medical Mutual realized a record-setting
recovery of more than $9-million in fraudulent or improper claims over a
48-month period. “Healthcare fraud affects the entire nation and costs each
and every one of us dearly,” said Shanahan, adding, “health insurance industry
experts estimate healthcare fraud amounts to $95 billion a year.”
The STARSentinel(TM) software, developed by ViPS, a WebMD company, enables
the Medical Mutual Financial Investigations unit to better detect fraudulent
and improper claims from doctors, hospitals, outpatient centers and
pharmacies. The program examines claims and calls attention to those that
differ dramatically from a healthcare provider’s history or the norms for a
given specialty or condition.
According to The Health Insurance Association of America, at least one-
fourth of health insurers’ claims are sent electronically. According to
Shanahan, insurers such as Medical Mutual find a screening device an essential
tool in reducing health insurance fraud and keeping healthcare costs from
escalating.
“ViPS StarSentinel software played a major role in all healthcare
provider-focused cases,” said John Shoemaker, manager of Medical Mutual’s
Financial Investigations. “StarSentinel either generated the direct lead or
was used to support the basis of a tip received,” he said.
“Some discrepancies may be simple mistakes of improperly filed claims due
largely to an office staff, which may not be well trained in billing claims,”
said Shoemaker. “The software is geared to identify these errors so that the
mistakes do not continue to happen.”
With this software, Medical Mutual routinely examines claims for a number
of issues, for example, how often a hospital bills for a certain procedure or
the frequency of a doctor writing prescriptions for the same drug. The
software can also pinpoint “doctor shoppers” — those who visit more than one
doctor to try to get prescriptions such as Oxycontin and other highly
addictive drugs.
More anti-fraud software is ready to go online this year at Medical
Mutual. “In 2004 we also purchased a software package that will assist us
further in identifying individuals, physicians, and pharmacies that are
abusing prescription drugs,” said Shoemaker. “We are working on bringing this
software on line early this year and both of these software programs will help
us to hold the line against health insurance fraud in 2005.”
About Medical Mutual: Founded in 1934, Medical Mutual is the oldest and
largest health insurance company based in Ohio. The company serves its
customers through high-quality, affordable group and personal health insurance
plans, and third-party administrative services to self-insured group
customers. Medical Mutual’s annual revenue in 2004 was $2 billion. Based in
Cleveland, Medical Mutual also has offices in Columbus, Cincinnati, Toledo,
Akron, Dayton and Youngstown. For more information, visit the company’s
award-winning Web site at http://www.MedMutual.com .
