FICO® Payment Integrity Platform

Healthcare Payers

Strengthening cost containment with the power of adaptive, predictive analytics

 

Overview

FICO® Payment Integrity Platform

Insurers play an increasingly critical role in helping to make healthcare both effective and cost efficient. This means ensuring that payments and claims are accurate, valid, and compliant with provider agreements. The FICO Payment Integrity Platform helps healthcare payers reach unprecedented levels of cost containment by applying adaptive, predictive analytics that assess the validity of healthcare payments. 

Comprehensive Analysis

Medical Policy

Cost Containment

Special Investigations Unit

Medical Policy

Medical Policy – Monitors for inappropriate medical services

Provider Management – Validates conformance with provider contracts 

Cost Containment

Cost Containment – Highlights services that may have been overcharged due to coding or billing errors

Claims Operations – Identifies services that should have been managed or bundled differently

Special Investigations Unit

Special Investigations Unit – Uncovers known and previously unknown cases of system manipulation

Solution Architecture

Adaptive, Predictive Analytics

Healthcare claims processing is not a static environment. Policies change, manipulation strategies evolve, and patterns emerge. Adaptive predictive analytics scour data for indications of anomalous behavior across members, providers, claims, and facilities. By applying machine-learning techniques, adaptive predictive analytics find previously unknown indications of payment discrepancy. Discrepancies that often evade detection by rules systems alone.

The foundation of the Payment Integrity Platform is FICO Insurance Fraud Manager. This proven technology coordinates the analytics, link analysis, business rules, and case management capabilities that help even the largest healthcare payers deliver value quickly. In fact, Insurance Fraud Manager can analyze up to one million claims per hour while prioritizing where to focus your limited review cycles for maximum return.

Customers

It's not just who we work with, it's how well we work together.

Key Features

  • Medical – Ranked scoring of medical claims, providers, and procedures
  • Dental – Provider scoring based on historical billing
  •         Facility – Inpatient and outpatient claims scoring at the aggregate facility level
  •         Pharmacy – Ranked scoring of pharmacy claims, providers, and procedures

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Leading Healthcare Payer Tightens Grip on Fraud

Highmark

Within the first few months of implementation, Highmark Special Investigations Unit (SIU) identifies 83 new fraud cases.  Find out how!