Fraud & Abuse Resolution

Cypress Benefits > Fraud & Abuse Resolution

Nobody matches the power and control of this program

$250B of waste in Health Care

Fraud and abuse, creative billing schemes, claim system deficiencies, lack of good and aggregated data, and transparency are all prime drivers.

Claim Systems have been designed for an environment that creates efficiencies in cutting checks with strong capabilities in managing Eligibility and Benefit Plans. Applied Risk Management requires a new dynamic!


	2002 – Aetna discloses 11% payment error rate 2003- BCBS Association estimates that 5-10% of healthcare claims are paid incorrectly. ( Business Insurance – March 2003) 2003 – Federal government negotiated more than $1.8B in judgments and settlements in health care and fraud matters. (Health Care Fraud and Abuse Control Program Annual Report by the DOJ and HHS). 2004 – CMS announced 9.1% error rate • 4 billion transactions annually – 6.3% error rate. (HHS-OIG) $150B in fraud is paid by commercial payers annually (National Health Care Anti –Fraud Assoc.) 54% of Physicians reported using deception of third party payors to obtain benefits

The big Carriers often do not apply the best capabilities to control costs in order to maintain discounts in their Networks – the result can be employers end up paying more!

Who is helping employers avoid more waste?

Over half of the country’s payors do not employ fraud detection technology;
BCBS Association 2003 Fraud Results: 0.18% of paid claims;
Class Action Lawsuit for arbitrary/unfair reimbursements:

o CIGNA - $540 million
o Aetna - $470 million
Business Intelligence is rarely applied to health care costs;
Cost containment programs, when applied, are typically done retrospectively.

o Retrospective Recovery avg. savings: 0.10/dollar
o Prospective Recovery avg. savings: $0.54/dollar

CYPRESS BENEFIT ADMINISTRATORS ADDRESSES RAMPANT HEALTH CARE WASTE THROUGH THE CYPRESS SOLUTION PROGRAM

CYPRESS BENEFIT ADMINISTRATORS EMPLOYS THE INDUSTRY’S LEADING EDGE COST CONTROL SOLUTIONS

Provider Integrity Programs
Data Driven Fraud & Abuse Prevention
Intelligent Claim Surveillance
Pre-Payment Investigations
Automated Code Edits
Provider R&C Negotiations

EMPLOYERS CAN EXPECT A REDUCTION IN OVERALL CLAIM COSTS OF 5% - 10% THROUGH THE EFFORTS OF THE CYPRESS MEDICAL RISK MANAGEMENT PROGRAM

NOBODY MATCHES THE POWER AND CONTROL OF THE CYPRESS MEDICAL RISK MANAGEMENT PROGRAM, AN INTEGRAL PART OF
THE CYPRESS SOLUTION!

Consumer Info Links

Employer Resources

Fraud and Abuse Medical Risk Mgmnt (Powerpoint)

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