Specifications include, but are not limited to: The Office of the State Auditor (“Auditor” or “State”) is soliciting proposals from qualified contractors with extensive expertise in workers’ compensation and workers’ safety to complete a performance evaluation of certain aspects of North Dakota Workforce Safety and Insurance (WSI). This performance evaluation is to identify areas of potential improvements and the contractor is to make recommendations for improvement to WSI operations where applicable. We recommend that WSI develop techniques in data mining to detect fraud, notably as regards medical providers given the relative lack of provider fraud detected not only in the performance evaluation period but before that as well. We’re not sure what the data mining results will be but we provide two examples. First, let’s say within the bill review area that WSI tracks the frequency with which certain follow-up office visit codes are used by medical providers in the state. WSI may learn that many providers use relatively simple or low-level procedure codes when submitting their bills for reimbursement. Other providers may tend to use higher, more complex codes. Such trends can then be measured and filtered by provider as a way of better understanding individual provider billing practices and validating that the more complex codes are justified or not, as the case may be. A broad-based metric tied to this effort would be a report that sorts by billing code and then monitors how trends may change over time. A second approach should be tied to Recommendation 6.4 in the Narcotics Utilization section of this report where we recommend provider profiling. Once prescribing patterns are better understood, something may be gleaned from the analysis that suggests fraud or at least a need to educate providers who are outliers when compared to their peers.
