GEHA catches fraud before payout while improving case targeting twelve-fold

Government Employees Health Association (GEHA) was facing a major challenge: to improve the efficiency of its rules-based, manually intensive fraud detection system that analyzed more than 6 million claims a year. GEHA is the third largest national health plan serving federal employees, retirees and their dependents, with more than 230,000 health plan subscribers and 450,000 insured lives.

“Like many other carriers, we were trying to increase the number of claims processed electronically and without adjuster intervention,” says Bob Greene, manager of Data Analysis at GEHA. “At the same time we did not want to advance automated review at the expense of letting fraud get by.