Healthcare auditors / fraud investigators are prime candidates for using data mining software tools in their work. WizRule, WizWhy, and WizSame should be used in investigations involving dental claims, workers compensation claims, disability claims, prescription plan claims and long term health care claims.
Here is a list of applications that should gather the attention of the audit selection maker:
- Patient substitutions
- Over-utilization of specific diagnoses inconsistent with the patient population
- Excessive number of patients traveling great distances to a provider (could indicate provider utilizing a postal drop site)
- Provider open seven days a week for disproportionate number of non-emergency procedures (could indicate provider is filing false claims and is spreading out the submissions to divert suspicion)
