SAN RAMON, CALIFORNIA (March 1, 2022) - 4L Data Intelligence announced that Clay Wilemon has been named Chief Executive Officer and Chairman. His appointment is the result of an upgrade of the company's financial, marketing and operations systems to prepare the organization for significant growth acceleration. Clay previously served as President and Chief Commercial Officer since October 2021.
Theja Birur, company Founder and Chief Technology Officer said, "Clay's experience in brand development, leadership and commercialization is key to our next phase of success. Our FWA Prevention & Recovery and Provider Intelligence & Integrity solutions have been validated across millions of claims and providers. The technology is ready for rapid expansion, and we will benefit from Clay's background of defining and launching over 500 new brands into healthcare and technology markets."
Clay Wilemon added, "The patented Integr8 AI technology platform developed by Theja and our engineering team is proven to help healthcare providers and payers, insurance companies and governments improve service quality, serve more people and lower costs by improving data, provider, payment and decision integrity. This gave our new investors confidence that the company is clearly out of the development and validation phase and ready for significant commercial growth."
Clay is founder and former CEO of DevicePharm, a strategic marketing firm that helped define and launch over 500 new healthcare and technology brands. DevicePharm was acquired by a private equity firm. In addition, Clay has been an active investor and director in healthcare, technology and artificial intelligence companies and is a partner in Visionary Ventures. He is also a member of the Board of Directors at Octane, a Southern California economic development organization that has helped early-stage Orange County tech and med-tech companies raise over $4 billion in funding in the past decade.
The 4L Data Intelligence mission is to USE THE POWER OF INTEGR8 AI TECHNOLOGY FOR GOOD by helping healthcare payers, health systems, governments and insurers deliver better services and care and reduce trillions of dollars in out of-control costs by making actionable data accessible in real-time, automating inefficient processes and preventing fraudulent, wasteful and abusive payments that drive up costs. We do this by improving integrity at four levels: data integrity, provider integrity, payment integrity and decision integrity.
For more information, visit the company website at www.4LData.com.
A 2021 4L Data Intelligence analysis of over four (4) million workers compensation claims paid showed that 19,612 providers out of a network of 86,000 submitted fraudulent claims totaling about 10% of all claims paid during the prior year. This study was conducted retrospectively using 2020 claims and network provider data for a regional workers compensation payer that paid about $107 million in fraudulent, wasteful or abusive claims on approximately $1.17 billion in total payments.
4L Data Intelligence deployed our Provider Intelligence & Integrity and FWA Prevention & Recovery solutions to retrospectively evaluate the integrity of previously paid claims, provide automated support data for recovery and increase real-time, pre-adjudication FWA prevention on future claims. Each of the 4L Data Intelligence solutions used in this analysis are powered by our patented Integr8 AI technology platform.
The findings in this regional workers' compensation study were similar to other analyses performed with the patented Integr8 AI technology platform. Most of the FWA activity identified retrospectively could have been detected and prevented in real-time using 4L Data Intelligence solutions on a continuous basis.
The first set of preventable FWA findings in this analysis were related to the provider network itself. Almost 23 percent (22.8%) of providers were flagged for some level of FWA activity. Twenty-two (22) providers were practicing with OIG, SAM or other health sanctions and should not have been in this or any other provider network. Numerous providers were practicing with multiple tax ID numbers and hundreds of others had problematic collusion maps noting high-risk relationships with DME providers, pharmacies, or other healthcare professionals. All of these providers could have been identified upfront and eliminated from the network before they were able to commit fraudulent, wasteful, or abusive actions with our Provider Intelligence & Integrity solution insights around providers' demographics, status, relationships, and behaviors. And this same solution performs continuous integrity monitoring to identify providers with integrity risks on a daily basis.
The second set of preventable FWA findings center around coding and other detectable and preventable behavioral 'red flag' anomalies. Common findings included: 1) suspicious drug prescriptions with specific CPT codes, 2) outlier procedures associated with a particular ICD code or provider type and 3) procedures billed outside of evidence-based guidelines. All of these FWA-related anomalies and more are detectable and preventable in real time with Integr8 AI continuous surveillance that enables literally every claim to be audited against millions of complex combinations of CPT and ICD-10 codes and payer guidelines as well as against individual and collective provider behaviors and relationships.
The 4L Data Intelligence FWA Prevention & Recovery solution used in this analysis, proved to provide immediate and detailed intelligence for quantifying and documenting FWA activity by provider. Think of it as an FWA case file at the press-of-a-button.
This enables recovery efforts to begin quickly and equips program integrity units and collectors with deep provider-specific data to align recovery efforts as closely as possible with the action, creating a very favorable scenario for collection.
This analysis demonstrated a number of macro-actions that the payer could take to mitigate future FWA risk. These steps included: 1) extract rendering provider information from PDF images, 2) manage invalid or missing data problems by back-walking based on known attributes, 3) improving the plan design and 4) improving formulary design.
The workers compensation payer study demonstrated that detecting and preventing FWA claims real-time BEFORE the claims are paid, can literally save payers millions of dollars each year in the of over-payment and collection costs.
It also proved that the 4L Data Intelligence Provider Intelligence & Integrity solution and the FWA Prevention & Recovery solution are powerful tools for recovering FWA over-payments, but also in detecting and preventing the cost, time, and manpower burden of recovering fraudulent payments.
To schedule a free Provider Integrity Scan or a FWA Prevention data scan, contact info@4LData.com
Surfers talk a lot about sets, groups of waves that keep coming one behind the other. While that may be a surfer's dream, the continuous cadence of telehealth fraud, waste and abuse stories is looking more like sets of tsunamis coming one after the other.
The dollar amounts of charges brought by the U.S. Department of Justice for telehealth and telemedicine fraud are staggering. Indictments for $4.5 billion and $1.2 billion are just the tip of the iceberg in a telemedicine market that is growing by 26.5 percent per year and expected to reach $475 billion by 2026. It's a big market with a big fraud, waste and abuse problem.
When examining some of the telehealth or telemedicine indictments a few common characteristics scream off the page. Relationships between dishonest doctors, pharmacies, labs and equipment or supplies providers are endemic in almost every case. In short, collusion between bad actors is part of each major fraud case.
The other common characteristic is that it does not require very many fraudulent providers to do a lot of damage. In a Florida telehealth fraud case announced May 3, 2021, the Department of Justice charged only three men in a $47 million healthcare fraud, kickback and money laundering scheme. In the $4.5 billion case referenced above, 86 providers were charged. And the $1.2 billion case involved only 24 people. Those are all very tightknit groups of providers united to engage in telehealth fraud.
Healthcare payers including government agencies, private insurers and self-funded employers are all asking the same question, "How can we detect bad actors BEFORE they have the opportunity to commit fraud?. The answer lies in using advanced artificial intelligence technology to connect-the-dots between structured and unstructured data from related and unrelated sources.
4L Data Intelligence was recently awarded a core technology patent for our Integr8 AI data intelligence platform that powers a machine-learning model trained using representations of a set of resource requests and authorization determinations to identify and adjudicate behaviors and transactions that are representative, or predictive of operational threats. In simple language, our 4L Data Intelligence Provider Intelligence & Integrity solution, powered by Integr8 AI, can be used to identify problem providers, relationships and behaviors in real-time. Here is how it works.
The 4L Data Intelligence Provider Intelligence & Integrity solution, powered by Integr8 AI uses provider data, payer data, public data and our own proprietary database of 7 million NPIs to immediately and continuously detect problematic activity in any provider network. The immediate output is detection of unauthorized providers, fraudulent providers operating under aliases, potentially fraudulent providers and potential collusion and relationships that point to fraudulent intent. And, because fraud and fraudulent providers are dynamic, the 4L Data Intelligence Provider Intelligence & Integrity solution, powered by Integr8 AI provides continuous surveillance to detect changes in provider demographics, status, behaviors and relationships that are indicators of new fraudulent behaviors.
Immediately and continuously identifying potentially fraudulent providers is one-half of the solution. The other half is detecting potentially fraudulent claims BEFORE they are paid.
4L Data Intelligence FWA Prevention & Recovery solution, powered by Integr8 AI reduces healthcare fraud waste and abuse by automating real-time financial, clinical and behavioral insights that help detect, prevent and recover fraudulent claims payments pre-adjudication. The power of Integr8 AI automated machine learning literally enables every claim to be analyzed with millions of combinations of CPT, ICD-10 and other code data along with payer guidelines and the provider network data.
This powerful fraud-fighting solution is on 24/7 empowering payers to stay ahead of fraudulent providers and reduce the amount of FWA leakage that gets through the system.
4L Data Intelligence is committed to providing the data insights to help healthcare payers immediately and continuously reduce risks to improve clinical and financial performance. Our Integr8 AI powered solutions provide a much-needed technology to keep the telehealth and telemedicine markets clean and healthy.
For more information about the 4L Data Intelligence solutions discussed in this story, please contact us at info@4LData.com
The fraud, waste and abuse (FWA) cases and convictions being prosecuted by the Department of Justice point to the rising sophistication and negative impact a single provider, or small group of providers, can have on the healthcare system. The recent conviction of a physician known as the 'Fountain of Youth' doctor is the latest example of fraudulent activity that is now detectable and preventable using the 4L Data Intelligence patented Integr8 AI technology platform based on real-time and continuous machine and deep learning.
A Fox Chapel, PA cardiologist was sentenced to six and one-half years in prison on August 5, 2021 for his role in a fraud scheme involving more than $13 million in false insurance claims, according to the Pittsburgh Post-Gazette.1 The fraudulent behavior occurred between 2008 and 2013 and included claims submitted to private health insurance companies as well as government insurance programs for an outpatient treatment called External Counter Pulsation.
These same common fraud characteristics can now be detected and prevented...
Dr. Samirkumar J. Shah's was a textbook for how providers have been able to commit fraud in the past. These same common fraud characteristics can now be detected and prevented BEFORE fraudulent claims are paid. When you examine the characteristics of Dr. Shah's fraudulent behaviors you see the following behaviors that are common in fraud cases:
So, what's the answer to detecting and preventing healthcare fraud like that committed by Dr. Shah? The 4L Data Intelligence FWA Prevention & Recovery solution, powered by Integr8 AI reduces healthcare fraud, waste and abuse (FWA) by automating real-time financial, clinical and behavioral data insights that help detect, prevent and recover fraudulent claim payments.
The blatant anomalies in his claims would have been identified in near real-time using Integr8 AI .
The key to stopping fraud before payments are made is detecting anomalies in relationships, behaviors and outcomes in a way that immediately and continuously reduces risk. Automated structured and un-structured machine-learning empowers 24/7 surveillance of financial and clinical claims data and interrogates every claim against millions of data points including ICD-10 codes, CPT codes, payer guidelines, collusion maps, patterns and relationships with other providers. More importantly, this technology interrogates each provider's behaviors and relationships around a claim and in relationship to other providers across all claims to identify FWA patterns and trends that help to identify FWA risk before it becomes a big problem.
In addition, the 4L Data Intelligence proprietary database of 7 million providers adds another powerful layer of financial and demographic sophistication to this surveillance. In doctor Shah's case, the blatant anomalies in his claims would have been identified in near real-time using the Integr8 AI artificial intelligence technology platform.
FBI Special Agent in Charge, Robert Jones said, "Health care fraud is a fundamental problem that impacts every American. It takes critical resources from our health care system and increases health care costs for everyone."
My work in both the Canadian and American healthcare systems showed me the extent to which care quality and quantity are compromised because of fraudulent actors. Our initial commercial deployment of the 4L Data Intelligence FWA Prevention & Recovery solution, powered by Integr8 AI showed us that this fraud, waste and abuse involves a range of 1.5 to 20 percent of providers depending on the network.
Most fraudsters' relationships, collusions and behaviors are generally the same, and they are now detectable in real-time. That is why I was motivated to build the Integr8 AI artificial intelligence platform. Healthcare needs this type of technology to fix what is estimated to be a $700 billion problem in the United States.1 Torsten Ove, Pittsburgh Post-Gazette, August 5, 2021
For more information about the 4L Data Intelligence solutions discussed in this story, please contact us at info@4LData.com
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EXCEPT AS PROHIBITED BY LAW, YOU WILL HOLD US AND OUR OFFICERS, DIRECTORS, EMPLOYEES, AND AGENTS HARMLESS FOR ANY INDIRECT, PUNITIVE, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGE, HOWEVER IT ARISES (INCLUDING ATTORNEYS' FEES AND ALL RELATED COSTS AND EXPENSES OF LITIGATION AND ARBITRATION, OR AT TRIAL OR ON APPEAL, IF ANY, WHETHER OR NOT LITIGATION OR ARBITRATION IS INSTITUTED), WHETHER IN AN ACTION OF CONTRACT, NEGLIGENCE, OR OTHER TORTIOUS ACTION, OR ARISING OUT OF OR IN CONNECTION WITH THIS AGREEMENT, INCLUDING WITHOUT LIMITATION ANY CLAIM FOR PERSONAL INJURY OR PROPERTY DAMAGE, ARISING FROM THIS AGREEMENT AND ANY VIOLATION BY YOU OF ANY FEDERAL, STATE, OR LOCAL LAWS, STATUTES, RULES, OR REGULATIONS, EVEN IF COMPANY HAS BEEN PREVIOUSLY ADVISED OF THE POSSIBILITY OF SUCH DAMAGE. EXCEPT AS PROHIBITED BY LAW, IF THERE IS LIABILITY FOUND ON THE PART OF COMPANY, IT WILL BE LIMITED TO THE AMOUNT PAID FOR THE PRODUCTS AND/OR SERVICES, AND UNDER NO CIRCUMSTANCES WILL THERE BE CONSEQUENTIAL OR PUNITIVE DAMAGES. SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF PUNITIVE, INCIDENTAL OR CONSEQUENTIAL DAMAGES, SO THE PRIOR LIMITATION OR EXCLUSION MAY NOT APPLY TO YOU.
We may terminate or suspend your account and bar access to Service immediately, without prior notice or liability, under our sole discretion, for any reason whatsoever and without limitation, including but not limited to a breach of Terms.
If you wish to terminate your account, you may simply discontinue using Service.
All provisions of Terms which by their nature should survive termination shall survive termination, including, without limitation, ownership provisions, warranty disclaimers, indemnity and limitations of liability.
These Terms shall be governed and construed in accordance with the laws of State of Delaware without regard to its conflict of law provisions
Our failure to enforce any right or provision of these Terms will not be considered a waiver of those rights. If any provision of these Terms is held to be invalid or unenforceable by a court, the remaining provisions of these Terms will remain in effect. These Terms constitute the entire agreement between us regarding our Service and supersede and replace any prior agreements we might have had between us regarding Service.
We reserve the right to withdraw or amend our Service, and any service or material we provide via Service, in our sole discretion without notice. We will not be liable if for any reason all or any part of Service is unavailable at any time or for any period. From time to time, we may restrict access to some parts of Service, or the entire Service, to users, including registered users
We may amend Terms at any time by posting the amended terms on this site. It is your responsibility to review these Terms periodically.
Your continued use of the Platform following the posting of revised Terms means that you accept and agree to the changes. You are expected to check this page frequently so you are aware of any changes, as they are binding on you.
By continuing to access or use our Service after any revisions become effective, you agree to be bound by the revised terms. If you do not agree to the new terms, you are no longer authorized to use Service.
No waiver by Company of any term or condition set forth in Terms shall be deemed a further or continuing waiver of such term or condition or a waiver of any other term or condition, and any failure of Company to assert a right or provision under Terms shall not constitute a waiver of such right or provision.
If any provision of Terms is held by a court or other tribunal of competent jurisdiction to be invalid, illegal or unenforceable for any reason, such provision shall be eliminated or limited to the minimum extent such that the remaining provisions of Terms will continue in full force and effect.
BY USING SERVICE OR OTHER SERVICES PROVIDED BY US, YOU ACKNOWLEDGE THAT YOU HAVE READ THESE TERMS OF SERVICE AND AGREE TO BE BOUND BY THEM.
Please send your feedback, comments, requests for technical support:
By email: email@example.com
By phone number: 925.217.4550