NHCAA Presents Investigative Excellence Award

ORLANDO, Fla., Nov. 19, 2013 /PRNewswire-USNewswire/ -- The National Health Care Anti-Fraud Association (NHCAA) today presented the Special Investigation Unit (SIU) of WellPoint, Inc. with its Investigative Excellence Award in recognition of the implementation of WellPoint's Predictive Modeling Tool, a unique and innovative approach to health care fraud-fighting.  

The WellPoint SIU has spent several years examining the concept of predictive modeling and for the last three years explored how best to leverage WellPoint's rich claims data in service of more effective fraud detection and prevention.  Bolstered with the knowledge it acquired, the SIU recently implemented new analytical technology and established a new organizational structure that incorporates use of an enterprise investigative team. The SIU serves as the focal point of this enterprise effort, developing internal, coordinated mechanisms across several WellPoint business units.

"WellPoint understands the direct correlation between innovation and our ability to effectively stay ahead of fraud, waste and abuse and we are committed to making the investments necessary to be successful," says Lee Arian, Staff Vice President of Program Integrity and Investigations. "Fraud prevention is essential for protecting patients."

The tools and interventions implemented by WellPoint as part of its predictive modeling effort saved more than $27 million in FY2013.

"This new investigative tool has shown us very surprising ways that enormous, messy and complex collections of data can be used to quickly identify fraud, abusive trends, systemic weaknesses and outright waste in our company," explains Alanna Lavelle of WellPoint. "These findings have demonstrated the compelling need for change—through adoption of medical policy, new edits in the claim adjudication systems, or different reimbursement policy." 

"In recent years, the health care anti-fraud field has been moving deliberately towards a greater focus on fraud prevention and anti-fraud models that incorporate predictive modeling and analytics, and this represents a fundamental shift from traditional health care fraud fighting," said NHCAA's Chief Executive Officer, Louis Saccoccio. "WellPoint has long been a leader of innovation for our field and their recent work in harnessing the power of predictive modeling is worthy of acknowledgment. NHCAA is proud to honor the WellPoint team with this year's Investigative Excellence Award."

The individual WellPoint employees being recognized are:

Lee S. Arian, Esq.
Staff Vice President, Program Integrity and Investigations

Michael D. Burnett, MBA
Senior Investigator

Dan Desmond
Process Improvement Director

Alanna M. Lavelle, MS, AHFI, CPC
Director, Enterprise Investigations

Diane Ward, RN, AHFI, MHSA, CCS-P
Clinical Fraud Director

The Investigative Excellence Award honors a private health insurer that has achieved significant results in the field of health care fraud investigations by employing innovative approaches to the investigative process. The award is being presented today at NHCAA's Awards Luncheon at the Rosen Shingle Creek. The luncheon is a function of NHCAA's Annual Training Conference; approximately 1,200 public- and private-sector health care anti-fraud professionals are in attendance to learn about fraud trends and emerging schemes, as well as to explore innovative solutions to combat health care fraud.

Founded in 1985, the National Health Care Anti-Fraud Association is the leading national organization focused exclusively on the fight against health care fraud. Our members comprise more than 100 private health insurers and those public-sector law enforcement and regulatory agencies having jurisdiction over health care fraud committed against both private payers and public programs.

SOURCE National Health Care Anti-Fraud Association