Information for Memo
UnitedHealth Group is a health insurance company that is organized in order to make a profit. They are headquartered in Minnesota. They are the largest health insurance company in the United States. They also have room to grow as they haven’t tapped the foreign market yet. The department my father worked in was fraud and abuse. That is just one aspect of the company as there is of course those who sell the plans, review applicants and plans, monitor spending, marketing, etc. All the aspects a business needs to function.
IS Consultant: audited claims and recovered money. Fraud to misbilling. Basically reviewing claims to get money. Some are honest reasons, some are not. Billions of dollars that are gone back after. Recovered billions each year. All types, physician to hospital, to personal. There are time limits, so some take more precedence than others for recovery and prosecution. Not just hospital and physician, members of the insurance also are dishonest. Hospitals will even give false diagnosis to insurance to get more money. It is basically a fight between people trying to get the money and United Health Group trying to keep the money.
Day in the life. Talk to the customer to find out the result wanted. Find the data and parameters required to write the code to find the data to recover the funds. Then do the process and write the code, then submit it to the client in an access file or .xml or excel. Then write a report to them to explain the process and the results. All is on the consultant though, it is your job to find what the customer is looking for or you are wrong. You have to know the business or you are no use to the customer. This leaves it in writing and makes it official so the money can be reacquired and if necessary further action against a wrongful entity. It is all on the consultant to make sure the end product is sufficient because the bottom line is making money back.
Had to thoroughly make sure the explanations were understood. When programs are run, they must be analytically correct, or the information is meaningless. The main programs are called SAS and Sequel. They are a fourth generation language that uses the english language to code. You still have to be trained, but you essentially write what you want the program to find or sort by and then you analyze the result.
You have to be of use to the customer and the company. You must go beyond their expectations and exceed the basic requirement. You have to look at the project as a whole to give all the information to help them do their job easier. They don’t have the tools or computers, or the knowledge on how to understand it in order to make a recovery. It is up to you to analyze the data and decide if it applies to a small number of claims or millions of claims. If it is found that the insurance company was wronged, the fraudulent entity that tried to cheat the insurance company will have the money taken from them and then persecuted based on the data and reports written by the consultant. It is common for doctors to even double and triple bill in order to get more money than the services provided. The doctors see the insurance company as the crook and the insurance company sees the doctors and others as the crooks. It is a flawed system, but it is the system in place.
A common analysis is doctors with high dollar accounts. It is necessary to see why a doctor’s balance for services is high. Lower balance accounts are also looked at as many smaller fraudulent billings add up. There is also the problem of UnitedHealth Group not being the proper entity to be paying the claim. It could be another health account or medicare, then the doctor or insurance member trying to double bill and collect the money twice.
Matthew Rockley Writing Money 