Opera Solutions’ Healthcare Group is focused on delivering critical analytics services and software that help eliminate fraud, waste, and abuse (FWA) throughout the U.S. healthcare system while improving provider efficiency.
In 2012, Opera Solutions was selected by the Centers for Medicare & Medicaid Services (CMS) to provide the core data science and analytics execution engine for operational and fraud analytics supporting the recently rolled out Affordable Care Act (ACA) exchanges. Opera Solutions is now the single source of truth for enrollment data and the data reconciliation gateway between the ACA exchanges and issuers.
Our healthcare solutions utilize machine-learning technology to identify, extract, and manage anomalous events and activities in medical claims processing. Market results have shown that our patented machine-learning algorithms and ensemble methods are projected to uncover another 25% of both provider inefficiencies and FWA (fraud, waste, and abuse).
When hospitals run effectively and efficiently, they can deliver better patient care and foster better patient outcomes. Our healthcare solutions, which deliver advanced analytics and directed Best Actions as a service, provide dramatic improvements in productivity and efficiency for providers — without requiring new IT or infrastructure investment.
Our Hospital Revenue Leakage solution is an intuitive, cloud-based platform that works with your hospital’s existing system to find missing charges in patients’ accounts, both pre- and post-bill. It uses advanced machine-learning algorithms to identify missing hospital charges. Even when used in combination with legacy rules-based systems, it delivers 25–75 basis points of incremental revenue.
A simple user interface allows auditors to evaluate a prioritized list of patient accounts, submit account corrections, and provide feedback. And because it uses advanced machine learning, it improves over time and adapts automatically, which means you won’t have to update the system when rules and regulations change.
Finds more missing charges: Even if you’re using rules- or auditor-based systems, we can find you more missing charges — 25–75 additional basis points of revenue.
Makes auditors more efficient: Prioritizes accounts based on the probability that a detected charge is actually missing and the amount of revenue likely to be recovered by addressing the missing charge.
Easy management and oversight: Managers have quick and easy access to key auditor metrics such as volume of invoices reviewed and total dollars flagged.
Learns and adjusts automatically: Auditors can provide feedback that helps the system learn and improve on its own, without involving IT or management.
Our FWA Radar solution leverages pattern-based analytics to more efficiently and accurately find fraud, waste, and abuse in claims data. Not only does it find a higher number of outlier claims than rules-based systems, it returns fewer false positives, resulting in increased auditor productivity and higher cost savings.
Claim-level analysis — Finds anomalies in charges by comparing diagnosis, patient type, treatment, location, and more.
Provider data — Performs peer analysis of providers’ procedures, prescriptions, billing, and referral patterns at local and national levels.
Fraud networks — Broad, multi-dimensional analysis highlighting drug prescription imbalances, preferential billing vendors, and other indications of potential fraud networks.