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"Medical Mutual Recovers $4.5M from Fraudulent, Improper Claims"
"CLEVELAND -- Armed with new anti-fraud software, the financial investigations department of Medical Mutual of Ohio recovered more than $4.5 million in fraudulent or erroneous claims in 2004, the company reported yesterday. "This is a huge step in trying to keep a lid on rising health care costs," said Brien Shanahan, director of legal Affairs for Medical Mutual. Combined with figures for 2003, Medical Mutual realized a record-setting recovery of more than $9 million in fraudulent or improper claims over a 48-month period, Shanahan said. "Health insurance industry experts estimate health care fraud amounts to $95 billion a year," he added. "Health care fraud affects the entire nation and costs each and every one of us dearly."Software developed by ViPS, a unit of WebMD, enables the Medical Mutual financial investigations unit to better detect fraudulent and improper claims from doctors, hospitals, outpatient centers and pharmacies. The program examines claims and calls attention to those that differ dramatically from a health care provider's history or the norms for a given specialty or condition. According to The Health Insurance Association of America, at least one-fourth of health insurers' claims are sent electronically. The special software either generated the direct lead or was used to support the basis of a tip received, said John Shoemaker, manager of Medical Mutual's financial investigations unit."Some discrepancies may be simple mistakes of improperly filed claims due largely to an office staff that may not be well trained in billing claims," he explained. "The software is geared to identify these errors so that the mistakes do not continue to happen."With this software, Medical Mutual routinely examines claims for a number of patterns. For example, the software looks at how often a hospital bills for a certain procedure or the frequency of a doctor writing prescriptions for the same drug. The software can also pinpoint "doctor shoppers" -- those who visit more than one doctor to get prescriptions for Oxycontin and other highly addictive drugs."In 2004 we purchased a software package that will assist us further in identifying individuals, physicians, and pharmacies that are abusing prescription drugs," Shoemaker said. "We are working on bringing this software on line early this year and both of these software programs will help us to hold the line against health insurance fraud in 2005." Founded in 1934, Medical Mutual reported $2 billion in revenue for 2004. It is the oldest and largest health insurance company based in Ohio. Visit Medical Mutual at www.MedMutual.com"