FWA Explorer Tool

Healthcare Analytics • Healthcare Payors

Challenge

Even though a there are many instances of fraud and abuse by providers, the ability to efficiently discover sufficient evidence remains a significant challenge. Our solution provided a unique pathing tool to trace patient journeys and highlight pathways benefiting from standards.

Detect Fraud, Waste and Abuse across the Healthcare Payors population and give end users the ability to swiftly and succinctly generate insightful reports, in particular, by enabling the ability to query the patient journey identifying patterns from the event logs in a manner that the payor can confirm if deviating from standards (Non-EBM). To provide payors a pilot model they can use in parallel with existing cost-of-care models to consider potential additional insights to uncover abuse.

Our Approach

Using a scalable parallel platform with in-database analytics capabilities and functionality (pathing, geospatial, clustering, etc.), the tools was devised to provide rapid answers to healthcare metrics including Cost, Proximity (clustering) which was coupled with pathway deviations. Pinpoints outliers at a geographic and or provider level and explores pathing outliers within a tool for ease of accessibility.

Results

Developed a custom-made UI tool to showcase the comprehensive analysis capable of unearthing patterns, view the distribution of ICD Codes in the selection. There was functionality to select the chapter (Muscular-skeletal, Diabetes etc) for which Pathing Analysis is performed with visuals based on ‘Path Direction’. Extent of interest: Provider of Interest, who’s outlying on the final utilization with specific providers of interest breaching EBM guidelines. the resulting graphs and insights within a tool for ease of accessibility.

Business Value

The tool provided a easy way to navigate large volumes of patients’ journeys & providers breaching EBM guidelines. It was adopted by our client and became part of a packaged deal along the line of the big data platform and related services.