PGroup, LLC P  4 Pre and Post Payment Fraud and Abuse Detection • Historical Multi-Dimensional Predictive Modeling Suspicious Payment Identification System – Pre and post payment The Suspicious Payment Identification System is an expert system designed to provide you with cutting-edge technology, statistical procedures, and data mining capabilities to identify facilities, providers and suppliers that exhibit suspicious billing behaviors on a real-time basis. Using proprietary algorithms and technology, these aberrant billing behaviors are defined through a variety of information processes and sources.  The Suspicious Payment Identification System takes the claims information and evaluates three "risk statuses." • Treatment Status What services are being provided? Are they consistent with standard practices? What is the variation of treatment of similar patients by different peer group providers? • Health Status What is a patient’s severity level? What chronic conditions are represented? Are coexisting conditions present? • Financial Status Are payments consistent with clinical severity? What is the financial trend across related services? All things being equal, are payments higher or lower than expected? These statuses are all related in unique ways, especially when associated with either chronic or acute conditions. When these three "risk statuses" are misaligned, there is a very high probability of error. The Suspicious Payment Identification System continually updates and refines pre-defined reports and report templates to analyze specific billing behaviors, fraud schemes, and user- defined billing trends.  Automatic updates occur as new information is gathered and data are refreshed.  Additional services available include: • Bill review and audit by licensed healthcare professionals • Sign off of audit results by provider and recovery of overpaid claims • Out of network claims negotiation with sign off that member is not responsible for the balance   For more information or to arrange a pilot of the Fraud Identification System, please contact: Steve Massey smassey@p4pgroup.com 423-596-1700 Government and Law Enforcement agencies place the loss due to healthcare fraud and abuse at least at 10% of our nation’s annual healthcare expenditure. This is a tremendous loss and takes healthcare dollars away from both legitimate healthcare providers and recipients of healthcare services. Certainly, only a small percentage of health care providers and consumers deliberately engage in health care fraud. However, even a small amount of health care fraud can raise the cost of health care benefits for everyone. It is not surprising that claim overpayments are occurring so frequently.  The complexity of the industry’s various, often conflicting claims billing and processing rules, coupled with aging claims adjudication systems, are fueling this alarming increase. The P4P Group can work with your Claims Department and Special Investigations Unit to identify suspicious claims activity before you pay the claim. Based on over 14 years of experience with health care claims error identification and overpayment recovery operations for Medicare, Medicaid and Commercial Health Plans, we have customized our proprietary system to support your need for facility and provider auditing services.  The system optimizes the identification of health care claims payment errors by providing dynamic, state-of-the-art data management and business intelligence, cutting-edge analytic tools, and user-friendly reporting platforms that support program safeguard efforts. Our service can be set up and customized to meet your organization’s needs. We prefer to evaluate two years of claims history in order to establish a member’s health status baseline to maximize identification. The service is provided as a SaaS model or can be licensed. The program incorporates several major components:                                              || Home | Services | Contact | About Us | Healthcare Providers  | Healthcare Payers | Large Employers || Two Factor Authentication   High Security -Two factor = strong authentication -Two way = mutual authentication -Cognometric = personal authentication       User Convenience -No tokens to lose or forget -Fully mobile: use on any PC, iPhone etc. -Completely intuitive: works every time        Low Cost -Uses existing password infrastructure -No new servers or databases -Deploys in days –  not weeks           Contact Us  P4P Group is here to help. We know what it takes to be successful, and we stand behind our services. Please contact us for more information.