FICO Launches Payment Integrity Platform to Slash Fraud, Waste and Abuse in Health Care Insurance

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Integrated analytics help identify 30 to 40 percent more payment irregularities than traditional rules-based systems

SAN JOSE, Calif.—November 13, 2014—FICO (NYSE:FICO), the predictive analytics and decision management software company, today introduced the FICO® Payment Integrity Platform, which addresses health care payment fraud, waste and abuse with out-of-the box adaptive predictive analytics. This platform helps healthcare payers improve multiple aspects of their operations, including claims processing, medical policy, provider contracts, network management and compliance. With its integrated analytics and business rules technologies, the FICO Payment Integrity Platform can identify 30-40 percent more payment irregularities than systems based on business rules alone.

FICO is showcasing the Payment Integrity Platform at the National Health Care Anti-Fraud Association annual training conference in Dallas, November 18-20. On November 20, Allyn Pon, senior product manager at FICO, will speak on “Using Adaptive Predictive Analytics to Discover Facility Payment Schedule and Contract Issues.”

The FICO Payment Integrity Platform brings to bear three technologies for identifying potential claims irregularities, enabling corrective action to be taken before claims are paid. Adaptive predictive analytics find emerging fraud trends based on multi-faceted analysis of claims, providers and procedures. Link analysis looks for common data elements across claims. Business rules, authored by business users in FICO® Blaze Advisor® business rules management system, can identify problems based on known patterns and/or perform pre-processing on claims to highlight areas for analytic investigation.

“Business rules identify black-and-white cases, whereas analytics deal with uncertainties,” said Russ Schreiber, vice president of insurance solutions at FICO. “Together, they offer the best way to reduce the ens of billions of dollars lost to health care fraud, waste and abuse each year in the US alone. Part of the power in the FICO Payment Integrity Platform is that business users can quickly write and change their own rules without the need for IT support, as they spot new trends or need to implement new procedures. This is definitely the easiest to use and most flexible solution on the market.”

The FICO Payment Integrity Platform’s out-of-the-box analytics enable payers to perform fingertip data mining with a single click — no SQL programming skill or analytic expertise is required. With a customizable claim review workflow system, high scoring claims can be reviewed and decisioned in as little as 30 seconds, with the decision results fed back into the claims processing system to be denied or held for further investigation. In addition, fraud rings can be detected with link analysis, an integral component of the Payment Integrity Platform. The enterprise-class platform can handle medical, pharmacy, dental and facility claims, and can process hundreds of millions of claim lines for provider scoring in a single day.

Healthcare payers also have the option to access the FICO Payment Integrity Platform through a secure analytics as a service option. Payers submit their claims to FICO; the Payment Integrity Platform then analyzes the claims and returns the scored results with contextual reasons for high scores.

“With this unique service, the user doesn’t need to install or manage any software,” said Schreiber. “It’s ideal for smaller and medium-size payers who want the power of advanced predictive analytics at a lower cost. FICO pioneered this kind of service with credit bureau scoring, and we’ve now extended it into insurance claims analytics.”

“We’ve noted FWA solutions addressing evolving threats with increased accuracy, adaptability and cost-effectiveness,” said Sven Lohse, Research Manager at IDC Health Insights. “Technology solutions such as software as a service [SaaS] and cloud that are complemented by outsourced services (e.g., analytics as a service) are gaining broad acceptance among payers.i”

About FICO
FICO (NYSE: FICO) is a leading analytics software company, helping businesses in 90+ countries make better decisions that drive higher levels of growth, profitability and customer satisfaction. The company’s groundbreaking use of Big Data and mathematical algorithms to predict consumer behavior has transformed entire industries. FICO provides analytics software and tools used across multiple industries to manage risk, fight fraud, build more profitable customer relationships, optimize operations and meet strict government regulations. Many of our products reach industry-wide adoption. These include the FICO® Score, the standard measure of consumer credit risk in the United States. FICO solutions leverage open-source standards and cloud computing to maximize flexibility, speed deployment and reduce costs. The company also helps millions of people manage their personal credit health. FICO: Make every decision count™. Learn more at

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FICO, Blaze Advisor and “Make every decision count” are trademarks or registered trademarks of Fair Isaac Corporation in the United States and in other countries.

iIDC MarketScape: U.S. Healthcare Payer Fraud, Waste, and Abuse Solutions 2014 Vendor Analysis,” Sven Lohse, IDC, Document #248079, April 2014

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