FICO™ Insurance Fraud Manager—Health Care Edition delivers unprecedented value to payer organizations by substantially reducing losses from health care billing error, abuse and fraud. It’s the first system to detect these billing problems both prior to payment (through claim scoring) and after payment (through provider scoring). Detection is extremely precise at all of these points in the claims spectrum because FICO Insurance Fraud Manager analyzes claims data in the full context of historical billing behavior by the provider, its peers and other participants in the health care network. As a result, FICO Insurance Fraud Manager catches billing problems that are invisible to claims editing and adjudication systems, and even rules-driven fraud detection—including redundant payments submitted by different providers or masked by missing claim information, upcoding, collusion among providers and facilities, abusive billing taking advantage of policy loopholes, fraud related to quality of care issues and even emerging, unknown fraud schemes
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