STARS®Solutions Suite - General Dynamics Information Technology

C o m b a t i n g F r a u d , Wa s t e a n d A b u s e
STARS ®Solutions Suite
H E A L T H C A R E F R A U D P R O T E C T I O N A N A L Y T I C S

Healthcare fraud, waste
and abuse cost the
American healthcare
system more than
$68 billion annually and
account for at least
three percent of the
total amount spent on
healthcare annually. 1

Fraud, Waste and Abuse Protection
Other estimates by government and law
enforcement agencies 2 place the loss due to
healthcare fraud as high as10 percent of our
nation’s annual healthcare expenditure–or a
staggering $226 billion–each year. And they
anticipate the cost of healthcare will only
continue to rise, which means the price tag
associated with healthcare fraud, waste and
abuse (FWA) is expected to rise too.
No commercial or government health payer
organization can afford to write off this much.
Yet that happens when fraudulent claims are
unintentionally paid. Left unchecked, the enormous
cost of healthcare FWA threatens both
the quality of healthcare and access to care
for millions of Americans.
The General Dynamics IT
Advantage
General Dynamics Information Technology
has a broad and deep understanding of
healthcare billing, claims processing and
healthcare FWA. We have a proven track
record of quality-driven solutions, successful
implementations and service quality. When you
couple that with our well-earned reputation for
managing complex data extraction and integration
projects, you have a dynamic convergence
of abilities that can make a big difference in the
return on your healthcare information technology
(IT) investments and the quality of your
decision-making in an anti-fraud program.
At General Dynamics IT, we are experts in
collecting, analyzing and reporting data related
to FWA. Our work is backed by an organization
with more than 30 years of experience
aggregating and analyzing data - one with
more than 50 large-scale data warehouse
deployments, more than 2.5 billion claims
stored and analyzed annually, and more than
300 million covered lives analyzed annually.
Major government programs and 70 of the top
200 health plans use our healthcare informatics
solutions. You can count on keen insights,
rigorous analysis, smooth implementations and
superior service.
FAST FRAUD FACTS
• The U.S. spends more than $2 trillion
on healthcare annually. At least 3
percent of that spending–or $68
billion–is lost to FWA each year.
(National Health Care Anti-fraud
Association, 2009)
• In 2011, the Health Care Fraud
Prevention and Enforcement Action
Team (HEAT), comprised of the
Department of Justice and the U.S.
Department of Health and Human
Services, recovered more than $4
billion due to the departments’
anti-fraud activities. (HHS News
Release, April 4, 2012) 3
1. National Health Care Anti-fraud Association, 2009. http://www.nhcaa.org
2. Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Expenditure Projections 2007-2017.
Federal Bureau of Investigation, Financial Crimes Report to the Public, Fiscal Year 2007.
http://www.cms.hhs.gov/NationalHealthExpendData/Downloads/proj2007.pdf, http://www.fbi.gov/publications/financial/fcs_report2007/financial_crime_2007.htm
3. http://www.hhs.gov/news/press/2012pres/04/20120404a.html

Solutions for commercial, Medicare
and Medicaid lines of business.
The STARS ® Solutions Advantage
FAST FRAUD FACTS
Healthcare is a prime arena for FWA because
• Every $2 million invested by private
of the enormous dollar amounts that pass
health insurers in fighting healthcare
through health payers’ claims systems.
fraud returns $17.3 million in recoveries,
court-ordered judgments, plus That’s why payer organizations use edits and
bogus claims that were not paid and audits to protect the integrity of the payments
other anti-fraud savings. (National they make. But the fact is, routine claims edits,
Health Care Anti-fraud Association,
manual claims auditing and similar functions
2009)
are not enough to protect you against today’s
• Every $1 spent on Medicare fraud prevention
would stop $10 in fraud. (HHS,
sophisticated fraud schemes. The more automated
your system and the more smoothly
Miami Herald, August 11, 2008)
it functions, the easier it may be for fraudsters
• The 50 state Medicaid fraud control
units obtained a collective 1,230 to slip through inappropriate or fraudulent
convictions and total recoveries of claims.
more than $1.7 billion in recoveries
for both criminal and civil cases in FY Mandated processing efficiencies to meet
2011. (OIG, HHS) 4 provider and regulator demand have also
exacerbated the possibility of FWA in claims
processing systems. Questionable claims,
especially with electronic transactions, are
easily overlooked due to the need to quickly
process billions and billions of transactions.
Along the way, staff can be overwhelmed
because data is in different places and difficult
to compile. Reports are incomplete and cumbersome.
Manual fraud investigation techniques
take up too much time. The right questions go
unasked, and the answers remain undiscovered.
Cases are not prioritized.
Rely on an Integrated, Comprehensive
Solution for Maximum Efficiency
The STARS ® Solutions Suite can address these
challenges and more. In a systematic and
informed way, your data analysts, auditors,
investigators, nurses, provider outreach
personnel, financial analysts and program
integrity special investigations unit (SIU)
managers can:
• Identify potentially fraudulent providers
and members with STARSSolutions’
automatic generation of fraud leads that
pinpoint potential fraudulent behaviors.
4. http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/expenditures_statistics/fy2011.asp

STARSSentinel ... STARSInterceptor ... STARSInformant ... STARSCommander ... addressing the continuum of healthcare fraud, waste and abuse.
• Spot your top offenders with
STARSSolutions’ Score and Rank
feature that identifies the worst fraudsters
as compared to their peers.
• Safeguard against the latest fraudulent
schemes with quarterly fraud Rules Boosts
to ensure a fresh review for emerging fraud
schemes.
• Manage caseload from initiation to recovery,
with a solution that lets you create new
investigations; use workflows to assign,
route and prioritize cases; attach external
files; generate reports; track recoveries;
and measure success.
With STARSSolutions Suite, we can help
you discern innocent errors from outright
fraudulent intent. No other solution in the
marketplace provides the same level of
detection, automation, in-depth analysis,
integrated workflow and ROI. It can serve
as a powerful tool in decreasing FWA
losses, increasing recoveries, developing
provider educational programs and
optimizing operational efficiencies.
PROVEN ROI
“Since 1991, we’ve leveraged
STARS ® and your company’s
consulting expertise. My
requirement for any new
product purchased is that it
must pay for itself within a
year, and with your solutions,
I’ve never failed. Sometimes,
I’ve even doubled and tripled
my return.”
– A Mid-west
Blue Health Plan
PROVEN ROI
“By utilizing STARS ® Sentinel
as part of our process, we’re
targeting $1 million in recoveries
from overpayments for the
fiscal year.”
– A New York Health Plan

Physician Facility Pharmacy Dental
Data Analysts Auditors Investigators Nurses
POST-PAY
DETECTION
SUSPECT ALERTS
EMERGING PATTERNS
PRE-PAY
PREVENTION
SUSPECTS
INTEGRATED
COMPONENTS
FINDINGS
Claim History
Provider Data
Member Data
Reference Data
Statistical Models
Aggregations
Scores/Risk Metrics
FWA Rules Engine
Security
System Administration
User Administration
WORKLOAD
MANAGEMENT
DATA EVIDENCE
ROOT-CAUSE
ANALYSIS
AD HOC INVESTIGATIVE
ANALYSIS
Provider Outreach Administrative Staff Fraud Hotline Staff
STARS ® Solutions
STARS ® Interceptor
Pre-Pay Prevention
Close the loop between post-pay detection and
pre-pay prevention.
STARS ® Informant
Ad-hoc Investigative Analytics
Perform ad-hoc data exploration to fully support
the investigation process.
STARS ® Sentinel
Post-Pay Detection
Spot potential FWA automatically by identifying the most
suspicious providers and members.
STARS ® Commander
Workload Management
Manage workload/caseload throughout the life cycle with advanced
workflow features and reporting capabilities.

Find Out More
We offer a suite of solutions that leverages the power of
your healthcare information to help control costs and
protect you against healthcare fraud, waste and abuse.
Learn more about about STARS ® Solutions.
Online: www.gdit.com/health
Email: answers@gdit.com
Phone: 1-888-545-8477 x8010

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06/21/12
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