FICO^® Payment Integrity Platform

Medical Policy

Medical Policy – Monitors for inappropriate medical services.

Provider Management – Validates conformance with provider contracts.

Special Investigations Unit

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

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.

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 FICO^® 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.

‌  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.