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Case Study

EDIWatch Fights Health Insurance Fraud Faster with CoSort

Reviewer
Darick Jarvis, systems manager for EDIWatch, Inc.

Background
EDIWatch, Incorporated is the leading provider of antifraud solutions to the health care payer industry. Using more than 20 years of experience, EDIWatch has pioneered rules-based technology for health claims fraud detection, pre-adjudication and underwriting, and provides a complete suite of products for insurance carriers and TPAs to meet the growing need for an antifraud solution in the global economy. Clients are implementing this solution in departments such as Medical Affairs, Internal Audit and Provider Relations to improve productivity, efficiency and maximize significant savings to the payer. EDIWatch uses claims data, extensive rule sets, pattern matching, and internal and external reference data to guarantee increased productivity of investigative units, improved provider information for auditors and pattern documentation for adjudication. In particular, EDIWatch's SPOT (Systematic Profiling on Time) application is a fraud knowledge base containing rules and alerts that also takes patterns of behavior and historical data into account.

Platforms
EDIWatch's SPOT product exploits CoSORT's SortCL (Sort Control and Data Manipulation Language) application on Windows, Linux and IBM AIX server machines.

Problem Solved
Our initial problems with a legacy sort tool involved cross-platform application (job script) compatibility and licensing on open systems. The legacy product had divergent products across different platforms that required different expertise and sort parameters for each environment. IRI's CoSORT dispatched those concerns quickly, and as new implementations began, the SortCL data definition and manipulation language program within CoSORT also simplified our reporting applications, runtime statistics and the summarization of transaction data.

Product Functionality
The list of CoSORT's SortCL function capabilities is truly impressive. No other sort engine that we have tried has anywhere near the simultaneous processing capabilities of this product. Some, but definitely not all of these features, are report generation, sequence prechecking, high-speed sorting, joining, merging, filtering, arithmetic, summary functions, min/max, ranking and sequencing.

Strengths
IRI has really taken the time to listen to its customers and develop a product with an exceptional arsenal of features and options to solve nearly any requirement related to processing flat files. CoSORT data manipulations are valuable time savers, particularly because we can reduce the number of processing steps needed into a completely one-pass process. In addition, many integrated functions, such as averaging and arithmetic, did not exist elsewhere. These features in SortCL allowed us to save processing steps and time in some areas, while also reducing the amount of time needed for some system changes and client setups.

Weaknesses
In some cases, we would like to see more specific error messages when a job fails. The errors themselves are very descriptive, but it was occasionally difficult to determine what specific data or control parameter triggered the issue in the processing.

Selection Criteria
Our selection criteria were based on features, licensing options and price. After experience with the competing sort product, we knew that CoSORT's SortCL interface was superior and was our best choice for high-volume data processing jobs.

Deliverables
SortCL is one of several UIs delivered with the CoSORT package, and there are several interfaces to the SortCL language itself (command line, batch script, Java GUI, API call). However, the deliverable provided by SortCL in terms of EDIWatch's SPOT processing is a data file generated per the parameters in the SortCL job (text) script. These output files then serve as the basis for further processing steps such as rules analyses, summaries loaded into a database or further SortCL processing.

Vendor Support
IRI's technical support staff has gone above and beyond our calls to make sure that all of our needs and concerns were met with clear and informative answers. At one point, technical support was even provided on-site for assistance during a critical project implementation at a testing facility.

Documentation
CoSORT documentation quality is excellent. The documentation is kept up to date with each SortCL version enhancement.