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NCJ Number: 63821 Add to Shopping cart Find in a Library
Title: DESCRIPTION OF AMOEBA (AUTOMATED MEDICAID OVERUTILIZATION AND ERRONEOUS BILLINGS AUDITOR
Author(s): ANON
Corporate Author: Control Analysis Corporation
United States of America
Date Published: 1976
Page Count: 30
Sponsoring Agency: Control Analysis Corporation
Palo Alto, CA 94304
National Technical Information Service
Springfield, VA 22151
US Dept of Health, Education, and Welfare
Washington, DC 20201
Contract Number: SRS-500-75-0008
Sale Source: National Technical Information Service
US Dept of Commerce
5285 Port Royal Road
Springfield, VA 22151
United States of America
Language: English
Country: United States of America
Annotation: THE AUTOMATED MEDICAID OVERUTILIZATION AND ERRONEOUS BILLINGS AUDITOR (AMOEBA), A COMPUTERIZED AUDIT SYSTEM FOR DETECING OVERUTILIZATION, NEAR DUPLICATE PAYMENTS, AND CONFLICTING CLAIMS, IS DESCRIBED.
Abstract: THE SYSTEM WAS DESIGNED UNDER CONTRACT TO THE SOCIAL AND REHABILITATION SERVICE OF THE DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE (DHEW). AMOEBA CAN DETECT UTILIZATION SUCH AS EXCESSIVE PHYSICIAN VISITS PER PATIENT, EXCESSIVE SURGERY, AND EXCESSIVE INJECTIONS. NEAR DUPLICATE PAYMENTS DETECTED BY THE SYSTEM INCLUDE CLAIMS WITH NONIDENTICAL BUT CLOSELY RELATED PROCEDURES, CLAIMS FOR NURSING HOME AND ACUTE CARE ON THE SAME DATES, AND OTHERS. POTENTIAL CONFLICTING CLAIMS INCLUDE PRENATAL AND/OR POSTPARTUM CARE WHICH SHOULD BE INCLUDED IN THE FEE FOR OBSTETRICAL DELIVERY, PAYMENTS FOR MULTIPLE SURGERY WHEN THE SECONDARY PROCEDURE SHOULD COST LESS THAN IF DONE INDEPENDENTLY, AND OTHER CLAIMS. AMOEBA USES A STATE'S PAID CLAIMS FILE AND IS RUN AS FREQUENTLY AS DESIRED. THE SYSTEM IS FLEXIBLE, TABLE DRIVEN, EASILY UNDERSTOOD, AND EASILY IMPLEMENTED AND MODIFIED. IT CAN BE USED WITHIN THE FRAMEWORK OF A STATE'S EXISTING CLAIMS PROCESSING SYSTEM. IN ADDITION, AMOEBA CAN EITHER SUPPLEMENT OR BE INTEGRATED INTO A STATE'S MEDICAID MANAGEMENT INFORMATION SYSTEM. DHEW PAID FOR ITS INSTALLATION IN OREGON AND MAY PAY FOR INSTALLATION IN SOME OTHER STATES. DISCUSSION ALSO FOCUSES ON DATA ELEMENTS AND COMPUTER FACILITIES NEEDED FOR AMOEBA INSTALLATION, A SUMMARY OF AMOEBA'S ADVANTAGES, DETAILS OF THE INFORMATION IT PROVIDES, AND DATA FROM THE PILOT INSTALLATION IN OREGON. (CFW)
Index Term(s): Automation; Computer aided operations; Crime detection; Medicaid/Medicare fraud
To cite this abstract, use the following link:
http://www.ncjrs.gov/App/publications/abstract.aspx?ID=63821

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