FICO® Insurance Fraud Manager (IFM) detects more fraud, abuse and error in health care claims before payment and identifies suspicious providers as soon as aberrant behavior patterns emerge. IFM integrates with social link analysis and advanced predictive models, including neural networks, to analyze claims at up to real-time speeds. Models instantly detect problems that rules and queries alone miss, saving you the cost of illegitimate and incorrect claims, while increasing throughput by automatically settling most claims.
Features & Benefits
Advanced predictive models analyze finalized but not yet paid 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."
Automatically scores providers so you receive early alerts to aberrant billing or care patterns. It scans enormous volumes of claims data for recurring, suspicious activity, including unusual scheduling with a single patient, unusually expensive procedures and even patients being discharged and readmitted, indicating problems with quality of care.
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.
FICO predictive models detect sophisticated conspiracies invisible to rules and less advanced analytics. They notice small irregularities "flying under the radar" that can add up to huge losses. They also shine light on systemic holes through which repeated losses flow and prevent being blindsided by emerging fraud schemes.
Rapid detection and ranked fraud scores enable you to prioritize investigative workload. 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.
Used for post-payment analysis, identify more fraudulent providers. Find additional suspicious payments to previously identified providers, strengthening case evidence and increasing recovery amounts. Spot organized fraud rings using the visual tools of link analysis, and easily create displays revealing connections between disparate claims, patients and providers.
Insights White Papers
Sep 2010, No. 44