FICO™ Insurance Fraud Manager, Healthcare Edition

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Products > Decision Management Applications > FICO™ Insurance Fraud Manager, Healthcare Edition

FICO™ Insurance Fraud Manager, Healthcare Edition

The new release of FICO Insurance Fraud Manager (IFM) 3 detects fraud, abuse and error in healthcare 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.

FICO IFM - Healthcare Edition

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 providers sooner
FICO Insurance Fraud Manager 3 automatically scores providers every month. 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 3 instantly determines which claims to pay automatically and which to review. Adjusters dispatch most referred claims in 30 seconds to 3 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 expense-a single model performs more accurate and complex detection 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 3 directs reviewers to the most serious problems first and points to exactly what is unusual about them.
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.
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 a case management environment incorporating contextual best practices, flexible workflow and reporting within units and across dispersed organizations.
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.

Highmark achieves quick ROI

Highmark, one of the nation’s largest commercial payers, initially used FICO's fraud solution for postpayment detection of fraudulent and abusive providers, and is now implementing it for prepayment claims scoring as well. Savings from postpayment detection provided momentum for moving forward: A detailed review of the 200 top-scoring providers revealed 83 cases (including both new cases and additional suspicious claims on previously identified cases). The average dollars and recoveries of a single case covered 85% of the software acquisition cost.

"We wanted a tool to detect potential fraudulent activity automatically, and that's what sold us on FICO."

Denny Latsha, project manager, Highmark

"The best approach is to combine prepayment claims scoring with retrospective provider analysis."

Tom Brennan, SIU director, Highmark

Read the full Highmark success story