San Diego, CA – Mitchell recently announced its new Provider Data Explorer solution, which provides a holistic view of medical provider behavior in the P&C industry. Using data visualization, Provider Data Explorer enables both auto casualty and workers’ compensation claims organizations to analyze medical provider treatment and billing behaviors to identify irregular activities that may signal fraud, waste and abuse.
Fraud accounts for 5% to 10% of claims costs for U.S. and Canadian insurers, costing about $80 billion per year for all lines of insurance, according to the Coalition Against Insurance Fraud.
By providing visual depictions of claims data, the visualization tool compares medical provider behavior to that of their peers. Users can see provider peer-to-peer comparisons that can be used in a variety of ways, including easily pinpointing outliers in order to help identify potential fraudulent or abusive medical provider treatment or billing behaviors for investigation.
“With Mitchell Provider Data Explorer, claims organizations can now use provider data more effectively to help spot potential fraud, waste and abuse and improve processes for greater efficiency,” said Shahin Hatamian, Mitchell senior vice president for product management. “This new visualization tool is the first step in an ongoing initiative to help Mitchell clients leverage provider data for improved decision-making.”
The new data visualization tool tracks a variety of metrics related to provider behavior, including but not limited to treatment duration, treatment frequency, billing and adjustment behaviors, and procedure codes that, if incorrect, may disproportionately drive up the charged amount.
In addition to helping to detect potential fraud, waste and abuse, Mitchell’s customers have already reported success using Provider Data Explorer for a variety of purposes.
- Validation: Provider Data Explorer allowed one large insurance carrier to validate the charges of a provider compared to its peers across multiple counties. “We were able to visually see just how much that provider was an outlier,” the carrier said. “The ability to then see the actual claim-level detail and the specifics of the codes allowed us to hone in further and get some more detail around the provider’s billing habits.”
- Identification: Another large insurance carrier used Provider Data Explorer to help a claimant find a local physician who was accepting auto insurance medical benefits. “One of our adjusters had a claimant that was injured in an accident but couldn’t find a doctor that would accept auto insurance,” the carrier said. “With just a few clicks, we were able to use Provider Data Explorer to identify multiple providers that had billed us for auto claims in the claimant’s zip code and surrounding areas. The adjuster was then able to provide a list to the claimant of providers in his area willing to accept auto insurance.”
Medical provider data quality is a chronic issue, with the healthcare industry spending $2.1 billion annually to maintain provider databases. Provider Data Explorer utilizes Mitchell’s foundational provider data management capabilities, which work to resolve provider data quality issues, including duplicate records and inaccurate information.
“Many claims organizations don’t have a view into provider activity due to inaccurate and duplicate provider data,” Hatamian said. “This information gap can lead to many issues in the claims process, including inaccurate provider payments, inefficient processes and uninformed decision making.”
Mitchell Provider Data Explorer is currently available to Mitchell DecisionPoint® bill review customers and will be rolled out to Mitchell SmartAdvisor® bill review customers in phases through the end of 2020.
Source: Mitchell
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