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Fraud and abuse management for payers

The challenge

Quickly and accurately detect wrongful claims

To uncover fraudulent and abusive behavior, investigators and auditors sort through huge amounts of claims data to find suspicious behavior. Many rely on tips from fraud hotlines, or use spreadsheets and database queries to perform relatively simple analysis. The fraud and abuse management solution for payers from IBM can help transform this process by allowing investigators to sort millions of claims in minutes and rank providers by degree of potentially abusive behavior. By automating processes previously conducted manually, our fraud and abuse solution can improve productivity and help your organization detect fraud more quickly and accurately.


The solution

Advanced analytics to pinpoint fraudulent claims

The fraud and abuse management solution provides investigators with the tools and methods needed to systematically and scientifically find fraudulent claims buried in the millions 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 and pinpoint which claims are most likely to be fraudulent or 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 new behavior patterns to uncover new, creative fraud schemes. Through a graphical representation of the aggregated claims data, the solution provides detailed analysis identifying those providers who are submitting 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

Improve accuracy and productivity

IBM has worked closely with healthcare investigators to develop the fraud and abuse management solution for payers with both proactive and retrospective detection capabilities. Our approach to identifying fraud and abuse helps enable your business to:

  • Improve cash flow and reduce audit risk by identifying aberrant claims before submission.
  • Support a diverse range of fraud investigation capabilities before and after claims payment.
  • Sort millions of claims in minutes, and rank providers by degree of potentially abusive behavior.
  • Pinpoint claims most likely to be fraudulent or erroneous with advanced algorithms and analytical models.


The specifics

Transform fraud identification 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. Our fraud and abuse management solution may include the following technical components, though 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 abuse.
  • IBM® DB2® offers industry leading performance, scale and reliability on your choice of platform from Linux® to IBM 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.



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