FICO® Insurance Fraud Manager, Workers' Compensation Edition
FICO™ Insurance Fraud Manager, Worker’s Compensation Edition
Products > Decision Management Applications > FICO® Insurance Fraud Manager, Workers' Compensation Edition

FICO® Insurance Fraud Manager, Workers' Compensation Edition

FICO® Insurance Fraud Manager automatically spot claims fraud and abuse the moment it emerges in worker’s compensation cases, before losses accumulate. Save an average of $100-300 per claim across all claims reviewed.
Key Benefits
  • Detect fraud and abuse sooner
    Insurance Fraud Manager analyzes claims at first notice of loss—then re-analyzes them, including all previous and new claims activity, continuously. This automatic process detects fraud and abuse the moment it emerges in workers' compensation cases, before losses accumulate.
  • Increase claims processing efficiency and consistency
    Safely pay most claims automatically, speeding processing and freeing reviewers to focus on suspicious claims. All claims receive the same high level of scrutiny, regardless of claims volume, employee turnover or differences in adjuster experience and skill.
  • Accrue more savings from exception management
    Claim scoring reveals, as a side benefit, legitimate cases in need of exception management. Find these problems early, and take cost-saving measures sooner.
  • Identify employers who may be under-paying
    Insurance Fraud Manager also automatically scores employers for likelihood of premium underpayment, based on unusual patterns of job classification and coverage compared to their business peer group.
  • Focus staff  resources where they produce the greatest financial impact
    Scored claims are ranked by degree of risk and reason codes point to what is suspicious about them. Adjusters focus on claims where there is a strong potential to save money through early intervention. Low rate of false positives (legitimate claims scoring high for potential fraud) improves quality of SIU referrals.
  • Lower your total cost of ownership
    Precision scoring, reason codes and low rate of false positives (legitimate claims scoring high for potential fraud) combine to increase productivity and lower costs. Simpler system administration reduces expense—a single model performs more accurate and complex detection than thousands of rules, and without the burden of managing all of them.
Features
  • Catches fraud and abuse other systems miss
    Predictive models detect unusual behavior patterns too complex, subtle or new to write rules against. They perceive small claim variations that slip by other systems and quickly find changing and emerging fraud schemes.
  • Sees beyond rules to the bigger picture of workers' compensation fraud
    While rules examine small pieces of data at a time, predictive models analyze hundreds of data points and relationships simultaneously. They analyze each claim in the context of vast amounts of historical claims data—including all transactions—both for that claim and others like it.  
  • Includes management controls for more efficient operations
    Managers can adjust referral thresholds to reflect changing staff capacity and create business rules to direct high scorers to the right reviewers based on level of risk and potential savings.
  • Provides working models “out of the box”
    FICO keeps your cost of ownership low by delivering working models “out of the box” and raises your cost-benefit ratio by improving them over time. Simpler system administration lowers expense—models greatly reduce the number of policy rules to maintain.

Speak with a FICO representative about our solutions and your business needs by calling us:

US (toll free): +1 888 342 6336
International: +44 (0) 207 940 8718

Or email us using the form on this page. We look forward to speaking with you.
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