Cybersecurity
Balancing Data Security with Member Engagement
Written by: Erin Benson, Senior Director, Market Planning

We are living in a time where members have more access to their personal health information than ever as a result of digital health initiatives to improve portal adoption.  As members are taking more control of their health, there is …

How to Detect Overbilling in Complex Medical...
Written by: Tom Figurski, Senior Business Consultant for Program Integrity and Fraud, Waste and Abuse

It is difficult to distinguish true fraud or overbilling from normal variability across providers, specialties, and geographic regions. Medical services are complex; they depend on techniques that vary widely, and their outcomes are difficult to measure. Due to these variabilities, …

Understanding Pill Mills – Questions to Ask
Written by: Rick Grape, Director, Market Planning

“Pill mills” refers to the catchy name given to clinics, pharmacies or individual doctors who prescribe narcotic medications purely for profit. Often paid per visit and per prescription, they typically prescribe far more narcotics than legitimate physicians and usually for …

Is Your Health Plan Getting in with the Wrong...
Written by: Tom Figurski, Senior Business Consultant for Program Integrity and Fraud, Waste and Abuse

Remember when you were growing up and your parents cautioned against getting in with the wrong crowd? It’s the old “one bad apple will spoil the bunch” philosophy. The goal was to avoid bad behaviors and the trouble that follows. …

sober homes
The Top 4 Sober Homes Scandals Payers Need to...
Written by: Tom Figurski, Senior Business Consultant for Program Integrity and Fraud, Waste and Abuse

In the past few years, no doubt you’ve heard the opioid epidemic mentioned many times. The addiction to opioids in the U.S.—including prescription pain relievers, heroin and synthetic opioids like fentanyl—is a serious national crisis affecting public health and costing …

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