Hundreds of billions of dollars are lost to health care fraud, waste and abuse in the United States annually. What can be done to help health insurers detect and prevent both opportunistic and professional fraud within the health care claims process?
To fight fraud effectively, health care organizations must continually improve claims review to identify and investigate individuals (providers, patients, suppliers) and networks of individuals involved in collusion.
- Summarizes key advanced analytics components.
- Examines the challenges faced by Horizon Blue Cross Blue Shield of New Jersey.
- Shares case studies from organizations using advanced analytics to uncover fraud.
Director of Informatics, Clinical Data Warehousing
Horizon Blue Cross Blue Shield of New Jersey
Mike Occhipinti has worked for Horizon for more than 20 years. He has worked with many external vendors installing software geared toward health care analytics, HEDIS reporting, and fraud and abuse. Occhipinti has been the SAS contact for Horizon for the past 10 years and has used SAS® since 1993.
Occhipinti is now closely involved with the coordination and development of multiple analytical projects, including health care trend analysis, disease management program administration, physician profiling and ROI. He has chosen SAS Enterprise BI Server as the required software suite to launch Horizon into the 21st century and compete in the commercial insurance industry.
Julie Malida, FSA, MAAA
Principal for Health Care Fraud, SAS
Julie Malida is the Principal for Health Care Fraud at SAS in the Fraud and Financial Crimes global practice. She is responsible for the strategic direction of the SAS Fraud Framework solution set as it pertains to the global health care industry, as well as the health care fraud domain expert.
Malida has devoted more than 26 years to the health insurance industry, focusing on managed care and cost containment in medical claims. Most recently, she served as President of The Sentinel Group, a premier health care anti-fraud organization serving insurance companies, third-party administrators, workers' compensation entities, P&C carriers and other cost containment organizations.