Tag Archives: Insurance

Given the negative impact of fraud, waste and abuse on health care, it’s in every payer’s interest to focus on these problems. 

So how does a health care payer measure success in payment integrity? How much is enough?

Two of today’s hottest tech topics—cybersecurity and artificial intelligence (AI)––were well represented at recent conferences in insurance and banking, respectively: Advisen Cyber Risks Insights Conference and Bank AI Expo. Here’s my take.

We recently commissioned a study from independent research company Ovum on how organizations are tackling cybersecurity and what they plan to do next. Losses because of a data breach or other cyberattack can be severe, particularly when factors such as customer and shareholder confidence are taken into account. We therefore expected that cyber risk insurance would be an increasingly important way in which organizations are mitigating their risk. The results were far from uniform: The UK was the most insured country we surveyed, with 69% of respondents holding some kind of insurance, and the USA was the least insured – only 51% of US respondents had any kind of cyber risk insurance. Across the industries surveyed, financial services firms were the most likely to be insured (71%), and healthcare the least likely (26 percent). Even when businesses have invested in cyber risk insurance, it’s unlikely to cover them for all... [Read More]

Ever wonder how SulAmérica combats fraud, waste and abuse? In the video below, Umberto Reis, IT Senior Manager at SulAmérica, notes that of the multi-billion dollar Brazilian health insurance market, roughly 20% may be waste and abuse. Needless to say, it’s a challenging market in which to be profitable. To tackle this complex problem, the insurer uses a combination of FICO analytics and decision management solutions, including FICO® Blaze Advisor® Decision Rules Management System and FICO® Insurance Fraud Manager. This has allowed SulAmérica, the largest independent insurance group in Brazil, to become much more agile and drive continuous improvement. For more information on this success story with SulAmérica, read our blog post: How SulAmerica Fights Insurance Fraud, Waste and Abuse.

One of the biggest challenges in fraud detection today involves not credit but insurance claims. That’s one reason to celebrate this year’s winner of the 2015 FICO Decision Management Award for Fraud Control, SulAmerica. SulAmerica, the largest independent insurance group in Brazil, where fraud, waste and abuse can occur in nearly 20 percent of insurance claims. After only a year in deployment, SulAmerica is realizing R$1.2 million per month in savings. SulAmerica uses FICO® Insurance Fraud Manager, a solution that verifies that payments and claims are accurate, valid, and compliant with provider agreements. Insurance Fraud Manager is used within SulAmerica’s claim process to identify fraudulent claims, as well as waste through clerical or systemic error. “The month-to-month improvement in savings through denied claims has been outstanding,” said Fabiano Carraro, Intelligence Health Claim Superintendent at SulAmerica. “This solution is a fantastic example of the longstanding partnership between FICO and SulAmerica. FICO... [Read More]

I recently joined FICO as the General Manager for Global Fraud and Security Solutions, based in New York. I am joining FICO after almost 20 years in the payment card industry, and thought I knew what fraud was – namely unauthorized or fraudulent credit card transactions. In my brief time here, through very productive conversations with our clients in the financial industry and outside, I am realizing that I had significantly underestimated the breadth and challenges of what is fraud today. Not only are financial institutions challenged by traditional payment card fraud, there is growing pressures from retail banking fraud, e-banking, first-party fraud including fraudulent applications for new accounts such as mortgages, employee fraud, and of course the emergence of digital and mobile transactions which are still being defined. In addition, fraud in healthcare insurance and property & casualty (P&C) insurance continues to grow. These fraud challenges are global in... [Read More]