Case Study GEHA

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

Solution generates twelve-fold increase in effectiveness of case targeting

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."

FICO's technology allows us to catch many more potential fraudulent, abusive and erroneous transactions with a high level of accuracy prior to payment. The solution also allows us to keep pace with the volume of claims processed electronically, and takes pressure off manually identifying aberrant claims."
—Bob Greene, Manager of Data Analysis, GEH

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