Fraud Detection Solutions from IBM


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The healthcare fraud and abuse management solution for payers from IBM supports a diverse range of fraud investigation and management both before and after claims payment, including prevention, investigation, detection and settlement.

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Fraud Detection Solutions from IBM

  1. 1. IBM Sales and Distribution Healthcare payers Solution Brief Fraud and abuse management for payers Prevent and detect fraudulent claims To uncover fraudulent and abusive behavior, investigators must sort Highlights through millions of individual claims to find suspicious behavior, often relying on a pay-and-chase strategy—pursuing cases after claims have ● Support a diverse range of fraud already been paid. IBM has worked closely with healthcare investiga- investigation before and after claims payment tors to develop the fraud and abuse management solution for payers with both proactive and retrospective detection capabilities. ● Sort millions of claims in minutes and rank providers by degree of potentially abusive behavior A sophisticated, comprehensive solution Detecting suspicious claims activity—such as billing for services not ● Pinpoint claims most likely to be fraud- ulent or erroneous with advanced algo- performed, billing more expensive claims than the actual service ren- rithms and analytical models dered, overprescribing tests and medications, and requiring tests and ● Achieve rapid return on investment by procedures that are not medically necessary—is a difficult data- enabling investigators and auditors to intensive task. The fraud and abuse management solution for payers become more productive from IBM supports a diverse range of fraud investigation both before and after claims payment, including prevention, investigation, detec- tion and settlement. The solution can help you transform your fraud and abuse manage- ment strategy by analyzing claims data using prebuilt fraud detection models designed for the healthcare industry. These models have been developed in conjunction with fraud investigators working in the field, and include an updated library of 9,000 risk indicators that can be used like building blocks to build new models or change existing ones. Advanced algorithms developed by IBM Research can help pinpoint claims most likely to be fraudulent or erroneous. Our analytical tech- niques include evaluating nonstandard claims submissions and statisti- cal outliers, identifying patterns of abusive claims submissions and defining new provider segments to find previously unknown patterns of
  2. 2. behavior. Using a combination of data mining capabilities and graphi- cal reporting tools, the solution can help identify potentially fraudulent and abusive behavior before a claim is paid or retrospectively analyze providers’ past behaviors to flag suspicious patterns more effectively than the traditional manual process. © Copyright IBM Corporation 2010 Reduce wrongful payments and increase IBM Corporation Route 100 productivity Somers, NY 10589 Without the tools to systematically and scientifically uncover suspi- Produced in the United States of America cious claims, investigators must rely on tips from fraud hotlines, or use May 2010 spreadsheets and database queries to perform relatively simple analysis. All Rights Reserved The fraud and abuse management solution can allow them to sort mil- IBM, the IBM logo and are trademarks or lions of claims in minutes, and then rank providers by degree of poten- registered trademarks of International Business Machines tially abusive behavior. This can help speed and extend the ability to Corporation in the United States, other countries, or both. If these and other IBM trademarked terms are marked on their recover mistakenly paid claims and reduce wrongful medical payments. first occurrence in this information with a trademark symbol (® or ™), these symbols indicate U.S. registered or common Our approach to fraud and abuse detection helps enable investigators law trademarks owned by IBM at the time this information was published. Such trademarks may also be registered or and auditors to become more productive, handling broader caseloads common law trademarks in other countries. A current list of by automating processes previously conducted manually. Increased IBM trademarks is available on the Web at “Copyright and productivity can lead to enough accurately identified suspicious claims trademark information” at to help your organization achieve a rapid return on investment. While Other company, product or service names may be trademarks some of the business requirements may differ, our solution can also or service marks of others. address the needs of public payer plans, such as Medicaid, to help recoup dollars wrongly billed to the system. Please Recycle Transform fraud identification with IBM Collaboration with healthcare payers and our deep involvement with user groups allow us to offer you a fraud and abuse solution that can evolve as your business needs change. Our fraud and abuse manage- ment offering currently used by 30 public and private sector clients to identify and pursue suspicious claims. IBM brings together industry and process expertise, systems and business performance software, and our deep computing and advanced analytics capabilities to tackle your business challenges. For more information To learn more about the fraud and abuse management solution for payers, please contact your IBM representative or IBM Business Partner, or visit: HHS03005-USEN-00