FICO® Insurance Fraud Manager, Health Care Edition
Products > Decision Management Applications > FICO® Insurance Fraud Manager, Health Care Edition

FICO® Insurance Fraud Manager, Health Care Edition

FICO® Insurance Fraud Manager (IFM) detects fraud, abuse and error in health care claims before payment and identifies suspicious providers as soon as aberrant behavior patterns emerge. Accelerate claims processing while saving money by avoiding improper payments, increasing loss recovery and correcting systemic vulnerabilities-and do it with existing or reduced staff. The solution includes dental fraud detection and member lock-in identification, to widen your protection and bolster your payment integrity. Release 3.2 improves the offering by including models for independent diagnostic testing services such as MRI’s and CAT scans, enhancing summary reports and adding the capability to display select third party partner data on the Claim Review Screen.
Key Benefits
  • Limit losses up front by catching problems before cutting checks
    Advanced predictive models analyze adjudicated medical and pharmacy claims at up to real-time speeds. They catch fraud, abuse and errors that slip through rules and queries, improving payment integrity and minimizing "pay and chase."
  • Halt loss accumulation by identifying suspicious patterns sooner
    FICO Insurance Fraud Manager automatically scores providers, including pharmacies. Without investing staff time, you receive early alerts to providers whose billing or care patterns are aberrant compared to peers.
  • Meet prompt payment requirements by accelerating claims review
    Insurance Fraud Manager instantly determines which claims to pay automatically and which to review. Adjusters dispatch most referred claims in 30 seconds to 5 minutes, since most of the work traditionally required to determine what's wrong has already been done automatically.
  • Catch new fraud schemes and vulnerabilities other systems miss
    FICO predictive models detect problems too complex, subtle or new to write rules against. They find sophisticated conspiracies invisible to rules and less advanced analytics. They notice small irregularities "flying under the radar" of conventional defenses but adding up to huge losses. They shine light on systemic holes through which repeated losses flow. They protect you from being blindsided by emerging fraud schemes.
  • Focus investigators where they produce the greatest financial impact
    Rapid detection and ranked fraud scores enable you to prioritize investigative work. Automatically assign your most experienced investigators to cases where the risk of loss accumulation is high, as well as to cases with substantial recovery opportunity.
  • Increase recoveries by finding more fraud
    This system can identify more fraudulent providers than any other method when used for postpayment analysis. It also finds additional suspicious payments to previously identified providers, strengthening case evidence and increasing recovery amounts.
  • Lowest total cost of ownership
    Fraud management expense is reduced with intelligent tools that streamline review and investigation of high-scoring claims. Simpler system administration also reduces expenses-a single model performs more accurately than thousands of rules, and without the burden of managing all of them.
Feature Highlights
  • Ranks high-scoring claims and providers by degree of suspicion and provides reasons why
    Insurance Fraud Manager directs reviewers to the most serious problems first and points to exactly what is unusual about them. The solution includes medical and pharmacy claims and provider scoring as well as dental provider scoring. It also identifies patients for member lock-in; in other words, patients who need to be restricted to specific healthcare providers and/or pharmacies in order to prevent abuse.  Version 3.2 improves the prior version by adding models for independent diagnostic testing services such as MRI’s and CAT scans.
  • Sees beyond rules to the bigger picture of healthcare delivery
    While rules examine small pieces of data at a time, predictive models analyze hundreds of data points and relationships simultaneously. They spot care and billing patterns that are unusual for the peer group or suspicious in regard to care the patient is receiving from other providers.
  • Updates historical context with every transaction
    Massive amounts of historical data on the behavior and interactions of participants in healthcare networks is mathematically condensed into dynamic profiles. These are constantly refreshed with new data from incoming claims, preventing unnecessary payments as soon as new fraud, waste and abuse patterns emerge.
  • Combines Detection, Action and Investigation modules for complete fraud management
    In addition to detecting suspicious billing activity, the system helps your staff effectively manage referred claims and providers.
  • The Action module links scores, reasons and claims data, enabling reviewers to quickly understand problems and take the right actions
    The Investigation module provides an integrated case management environment, incorporating contextual best practices, flexible workflow and reporting within units and across dispersed organizations. Investigators have ready access to detection information, and the ability to easily manage any actions taken, including posting of estimated and actual recovery information.
  • Provides management controls for more efficient operations
    The system incorporates tracking tools that enable managers to maximize throughput and improve resource utilization. By adjusting the score threshold for referral, for example, they can align their review rate with current staff capacity.

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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