Naperville, Ill, (April 2, 2020) - Context⁴ Healthcare continues to provide our customers with the best in pre-built FWA detection analytics and data extracts. Recently we expanded the functionality of the Context⁴ Payment Integrity solution with targeted analytics to assist in detecting a number of expanding FWA schemes. We've also added several data extract capabilities to allow auditors and investigators easy access to data that is critical to analyzing aberrant provider billing and utilization behaviors. 

Trips to Nowhere

"Trips to nowhere" is a scheme that is becoming more prevalent; it involves non-emergency medical transportation services billed for patients on days when there are no associated medical services billed for that patient. These trips to nowhere can cost health plans thousands of dollars on a monthly basis. 

The Context⁴ "Trips to Nowhere" data extract is designed to provide you with a full set of claim data identified when there are claims for non-emergency medical transportation for patients on days when there were no medical services billed. 

Impossible Hours

Billing for more services in a day than the provider likely worked, otherwise known as "impossible hours" in a day, has revealed abusive billing patterns. These billings could be for services rendered to patients by less skilled medical staff but billed under the provider's NPI, or possibly billings for services not performed. Either way, the costs to health plans can be significant. 

The Context⁴ "Impossible Hours" claim data extract is actually two different extracts. One extract is designed to identify potentially excessive E&M time-based services, while the other is designed to identify potentially excessive non-E&M time-based services. Context has researched all time-based procedure codes and assigned the average number of units/minutes for those services, which we document. The user then gets to set a runtime parameter to tell the program the number of hours that are considered excessive. 

Provider Specialty Claim Data Extract

When auditors or investigators are researching potential FWA, it's sometimes important to be able to isolate experience data for a particular provider specialty. This can help to show patterns outside the norm for a peer group, or that members of a certain specialty are billing for services that are outside the norm for providers of that specialty. A recent very large federal fraud case was initially identified when it was found that a provider was billing for services that weren't typically billed by providers of that specialty. 

The Context⁴ Provider Specialty claim data extract allows users to extract claim data information for all providers of a specified specialty within a specified date range. Context has created a mapping of provider taxonomy codes to provider specialties (documented for user viewing), and it's this mapping that is used by the provider to isolate claims for the designated specialty. The user can further analyze the resulting claim data extract to identify aberrant activity outside of the peer group. 

Provider Claim Data Extract

When research is needed into the activities of a specific provider, it's necessary to isolate all the billing information for that provider. The Context⁴ Provider claim data extract allows the user to easily extract claim data information for a specified NPI within a specified date range. The results provide a user with a dataset of information            that can be analyzed to further the investigation. 


If you have any questions about these new analytics and data extracts, please contact Context's Client Success Team via phone at (800) 783-3378 or email at clientsuccessteam@context4.com. They can help you with how to use the functionality to further the protection of your health plan. 

Thank you very much for continuing to work with Context⁴ Healthcare. 

About Context4 Healthcare, Inc. Headquartered in Naperville, IL, Context⁴ Healthcare has more than 30 years of experience in software and data product development. Context is a leading provider of healthcare compliance and reimbursement solutions including Context⁴ Reference-based Pricing, Context⁴ Medical Payment Integrity, and Context⁴ Dental Payment Integrity. These solutions serve hundreds of provider, health system, and payer clients, positively impacting millions of lives globally.

www.context4.com