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Fraud and abuse management for providers

The challenge

Improve claims submission to speed payment

To detect inaccurate or erroneous claims, your staff must sort through large amounts of data to find claims inaccuracies. The fraud and abuse management solution for providers from IBM can transform this process, allowing claims sorting and ranking by degree of potential errors. This can help speed and extend your ability to quickly settle claims payment and prevent fraudulent or erroneous submissions that could result in penalties. By automating processes previously conducted manually, our fraud and abuse solution can improve productivity and help your organization take a smarter approach to managing fraud and abuse.


The solution

A comprehensive and sophisticated solution

The fraud and abuse management solution provides your claims submission staff with the tools and methods needed to systematically and scientifically find erroneous claims buried in the thousands of claims submitted each year. We begin by enabling the extraction of claims data to be analyzed. The data is then loaded into pre-built fraud detection models designed for the healthcare industry. These models have been developed in conjunction with fraud investigators working in the field, and include an updated library of 9000 risk indicators that can be used like building blocks to build new models or change existing ones.

The solution uses algorithms developed by IBM Research to analyze claims and pinpoint which claims are most likely to be erroneous. We use several types of analytics crucial to detecting fraudulent data, including outlier detection, comparing similar providers or claims to indentify deviant or non-standard submissions; predictive models, defining patterns of abusive claims submissions and segmentation models, defining previously-unknown behavior patterns. Our solution provides a graphical representation of aggregated claims data and detailed analysis identifying suspicious claims, including the specific reasons for why they are suspicious. This level of detail can be used to make smarter decisions about the amount financial risk due to fraud and error.


The benefits

Boost productivity and submission accuracy

IBM has worked closely with healthcare investigators to develop the fraud and abuse management solution which offers advanced analytics and automated processes for detecting and preventing erroneous claims before they are submitted to the patient’s insurance company. Our approach to fraud and abuse helps enable your business to:

  • Improve cash flow and reduce audit risk by identifying aberrant claims before submission.
  • Support the prevention, investigation, detection and settlement of inaccurate claims.
  • Sort claims data in minutes and rank submissions by degree of potential errors.
  • Pinpoint claims most likely to erroneous with advanced algorithms and analytical models.


The specifics

Transform erroneous claims detection with IBM

Collaboration with insurance organizations and our deep involvement with user groups allow us to offer you a solution that can evolve as your business needs change. Your customized implementation may include the following IBM products and services, but is not limited to IBM-specific products or hosted services:

  • IBM Research custom developed algorithms use several analytical models to help you flag potential claims errors.
  • IBM® DB2® offers industry leading performance, scale and reliability on your choice of platform from Linux® to z/OS®.
  • IBM WebSphere® application server provides efficient delivery and management of business applications and services.
  • IBM Cognos® reporting and dashboards enable your investigators to author, share and use reports that draw on data for better business decisions.
  • Hosted services for fraud and abuse management from IBM offer the ability to send IBM your data, have it analyzed and returned on demand.