FICO today released the latest version of FICO® Insurance Fraud Manager, the most advanced system for detecting and preventing healthcare insurance fraud, waste and abuse. FICO® Insurance Fraud Manager 3.3 integrates link analysis with business rules and predictive analytics, and also adds a facility model for detecting fraud at a hospital or an outpatient provider.
“Fraud has always been a part of the insurance business, but the magnitude of insurance fraud today is startling,” said Russ Schreiber, who leads FICO’s insurance practice. “Experts estimate the annual cost of health care fraud, waste and abuse in the US to be upwards of $700 billion, and last May one Medicare fraud scam alone racked up $452 million. Now, with FICO Insurance Fraud Manager 3.3, insurers have a better way to fight back.”
FICO Insurance Fraud Manager 3.3 boasts the first fully integrated link analysis capability with an insurance fraud application. Insurers who previously had to configure separate link analysis tools can now save time and improve results with an easy-to-use solution preconfigured to use health care claims data. With FICO Insurance Fraud Manager 3.3, insurers can investigate organised fraud rings using the visualisation capabilities of a proven link analysis tool set, and easily create displays that reveal connections between disparate claims, patients and providers.
“Integrating link analysis with Insurance Fraud Manager’s powerful analytics and our advanced business rules gives insurers three ways to combat fraud, waste and abuse,” said James Evans, vice president of network and financial management at McKesson Health Solutions, which provides Insurance Fraud Manager’s analytics to U.S. insurers via its InvestiClaim® solution. “This triple protection gives insurers a powerful tool for fighting fraud, waste and abuse.”
The new facility model in FICO® Insurance Fraud Manager 3.3 scans enormous volumes of claims data for recurring, suspicious activity at a hospital or an outpatient provider. Telltale signs may include unusual scheduling with a single patient, unusually expensive procedures, and even such issues as patients being discharged and readmitted, which can indicate problems with quality of care.
Universal American, which piloted this model with FICO, received a 2012 FICO Decision Management Award this month for its use of FICO Insurance Fraud Manager to control costs and prevent fraud losses. Universal American, a leading provider of health benefits to people with Medicare, have implemented the FICO Insurance Fraud Manager solution into their claims workflow prior to adjudication, and integrated it with their claims platform, Facets.
“One key to success in stopping inappropriate billing is to identify such bills before they are paid,” Tyrina Blomer, Medicare Compliance Officer at Universal American, said of the FICO Insurance Fraud Manager Solution. “We were able to identify and prevent $6 million in inappropriate billing over an 18-month period.”
FICO Insurance Fraud Manager detects fraud, abuse and errors in health care claims and identifies suspicious providers as soon as aberrant behavior patterns emerge. Providers can accelerate claims processing while saving money by avoiding improper payments, increasing loss recovery and correcting systemic vulnerabilities. Staff productivity increases via the system’s ability to prioritize work, rank-ordering claims by most egregious and most financially significant.
FICO Insurance Fraud Manager now scores claims from doctors, ancillary providers, pharmacies and health care facilities, as well as detecting fraudulent patterns associated with specific medical providers, pharmacies and dentists.
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