A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder
It is difficult to identify fraud, waste, and abuse (FWA) in substance use disorder (SUD) treatment. Insurers use outlier detection models to detect SUD-related FWA but these models require credible benchmarks based on cross-payer claims data. To our knowledge, these benchmarks have not been establi...
| Main Authors: | , , , , , |
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| Format: | Article |
| Language: | English |
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Elsevier
2023-11-01
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| Series: | Healthcare Analytics |
| Subjects: | |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S2772442523000011 |
| _version_ | 1797796089621905408 |
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| author | Sivagaminathan Palani Steven D. Pizer Cecille Joan Avila Austin B. Frakt Kiersten L. Strombotne Melissa M. Garrido |
| author_facet | Sivagaminathan Palani Steven D. Pizer Cecille Joan Avila Austin B. Frakt Kiersten L. Strombotne Melissa M. Garrido |
| author_sort | Sivagaminathan Palani |
| collection | DOAJ |
| description | It is difficult to identify fraud, waste, and abuse (FWA) in substance use disorder (SUD) treatment. Insurers use outlier detection models to detect SUD-related FWA but these models require credible benchmarks based on cross-payer claims data. To our knowledge, these benchmarks have not been established for SUD-related services frequently cited in fraud cases — drug screening, psychotherapy, and partial hospitalization. We used de-identified and aggregated data from FAIR Health’s national database of commercial claims, including ACA marketplace plans, from 2014 to 2018 to establish regional benchmarks. We provide additional benchmarks for providers in specialties that most frequently submit claims for patients with SUD. These benchmarks can either be used to determine if a provider’s frequency of claims per-patient-per-month is unusual, potentially signaling FWA, or within a common range for the region or specialty. Our findings can be used to improve detection of FWA – a critical step towards improving the quality of treatment. |
| first_indexed | 2024-03-13T03:28:54Z |
| format | Article |
| id | doaj.art-fa854f22fb794627a4b492a5819fb92e |
| institution | Directory Open Access Journal |
| issn | 2772-4425 |
| language | English |
| last_indexed | 2024-03-13T03:28:54Z |
| publishDate | 2023-11-01 |
| publisher | Elsevier |
| record_format | Article |
| series | Healthcare Analytics |
| spelling | doaj.art-fa854f22fb794627a4b492a5819fb92e2023-06-25T04:44:08ZengElsevierHealthcare Analytics2772-44252023-11-013100134A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorderSivagaminathan Palani0Steven D. Pizer1Cecille Joan Avila2Austin B. Frakt3Kiersten L. Strombotne4Melissa M. Garrido5Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA; Partnered Evidence-Based Policy Resource Center, Boston VA Healthcare System, Boston, Massachusetts, USA; Corresponding author.Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA; Partnered Evidence-Based Policy Resource Center, Boston VA Healthcare System, Boston, Massachusetts, USADepartment of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA; Partnered Evidence-Based Policy Resource Center, Boston VA Healthcare System, Boston, Massachusetts, USADepartment of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA; Partnered Evidence-Based Policy Resource Center, Boston VA Healthcare System, Boston, Massachusetts, USA; Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts, USADepartment of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA; Partnered Evidence-Based Policy Resource Center, Boston VA Healthcare System, Boston, Massachusetts, USADepartment of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA; Partnered Evidence-Based Policy Resource Center, Boston VA Healthcare System, Boston, Massachusetts, USAIt is difficult to identify fraud, waste, and abuse (FWA) in substance use disorder (SUD) treatment. Insurers use outlier detection models to detect SUD-related FWA but these models require credible benchmarks based on cross-payer claims data. To our knowledge, these benchmarks have not been established for SUD-related services frequently cited in fraud cases — drug screening, psychotherapy, and partial hospitalization. We used de-identified and aggregated data from FAIR Health’s national database of commercial claims, including ACA marketplace plans, from 2014 to 2018 to establish regional benchmarks. We provide additional benchmarks for providers in specialties that most frequently submit claims for patients with SUD. These benchmarks can either be used to determine if a provider’s frequency of claims per-patient-per-month is unusual, potentially signaling FWA, or within a common range for the region or specialty. Our findings can be used to improve detection of FWA – a critical step towards improving the quality of treatment.http://www.sciencedirect.com/science/article/pii/S2772442523000011Outlier detectionSUD-service related benchmarksFraud waste and abuseCross-payer claims dataProvider-level flagsANOVA |
| spellingShingle | Sivagaminathan Palani Steven D. Pizer Cecille Joan Avila Austin B. Frakt Kiersten L. Strombotne Melissa M. Garrido A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder Healthcare Analytics Outlier detection SUD-service related benchmarks Fraud waste and abuse Cross-payer claims data Provider-level flags ANOVA |
| title | A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder |
| title_full | A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder |
| title_fullStr | A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder |
| title_full_unstemmed | A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder |
| title_short | A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder |
| title_sort | benchmarking approach for characterizing providers patterns of treating patients with substance use disorder |
| topic | Outlier detection SUD-service related benchmarks Fraud waste and abuse Cross-payer claims data Provider-level flags ANOVA |
| url | http://www.sciencedirect.com/science/article/pii/S2772442523000011 |
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