We all use predictive analytics and when looking a medical claims to find patterns of abuse and fraud, this is good thing and why HHS has incorporated this into the processing of Medicare claims. Those patterns are there to find but all keep in mind depending on how much the parameters of these queries are utilized, you can also get some false positives and the company through many years has had the time and expertise to look at those. Data is data an depending on how the queries run and what they look for, that determines the results you see. You will never have 100% in this area by any means. If anyone could completely get rid of false positives in this area, everyone would be knocking on their door but this is analytics with humans, so it will never be, but can be improved.
“MIB, Inc. is the premiere provider of fraud detection information for individually underwritten life, disability income, long term care and critical illness insurance. MIB member companies rely on its Checking Service for the fast, secure aggregation and exchange of data to combat fraud, improve underwriting effectiveness and increase product line profitability while ensuring fair pricing for all applicants.”
Again I am not saying that there’s not room for improvement as there is, but nobody and I mean nobody can accurately predict some of this as the money you save today might be spent on a new drug, device or crisis tomorrow and that is the unknown…better know as life. The MIB has their write up on diabetes too with predictive algorithms and risk assessment so they can take your numbers and mxi them with other data they have around and supposedly are able to predict about when you will die or how many years you have left, but the human body has been known to fool many, so again not 100%.
UCSF Medical Center Reduced Readmissions With Heart Failure And It Was Not That Magical Flipping Algorithm Everyone Is Looking for That Did the Trick
I also wonder if their analytics are so right on target, how this happen with the AAFP confronting them on the fact that in many areas of the US through complex contracts that they are paying doctors less than Medicare? Is that legal? I don’t know but United said they were surprised this was happening?
“UnitedHealth touts predictive modeling as solution to healthcare fraud and preventable hospitalizations”