Fico unleashes new analytics for fighting america's $700+ billion healthcare fraud, waste and abuse problem
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Fico unleashes new analytics for fighting america's $700+ billion healthcare fraud, waste and abuse problem

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FICO Insurance Fraud Manager 3.3 adds link analysis, facility model to boost detection of fraud rings and suspicious providers ...

FICO Insurance Fraud Manager 3.3 adds link analysis, facility model to boost detection of fraud rings and suspicious providers
MINNEAPOLIS, Oct. 2, 2012 -- /PRNewswire/ -- FICO (NYSE:FICO), the leading provider of predictive analytics and decision management technology, 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 organized fraud rings using the visualization 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, has implemented the FICO Insurance Fraud Manager solution into their claims workflow prior to payment, and integrated it with their claims platform, Facets.

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    Fico unleashes new analytics for fighting america's $700+ billion healthcare fraud, waste and abuse problem Fico unleashes new analytics for fighting america's $700+ billion healthcare fraud, waste and abuse problem Presentation Transcript

    • BP HoldingsFICO UNLEASHES NEW ANALYTICS FOR FIGHTING AMERICAS $700+ BILLION HEALTHCARE FRAUD, WASTE AND ABUSE PROBLEM
    • FICO Insurance Fraud Manager 3.3 adds linkanalysis, facility model to boost detection of fraud rings and suspicious providers MINNEAPOLIS, Oct. 2, 2012 -- /PRNewswire/ -- FICO (NYSE:FICO), the leading provider of predictive analytics and decision management technology, 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. 2
    • "Fraud has always been a part of the insurancebusiness, but the magnitude of insurance fraud today isstartling," said Russ Schreiber, who leads FICOsinsurance practice. "Experts estimate the annual costof health care fraud, waste and abuse in the US to beupwards of $700 billion, and last May one Medicarefraud scam alone racked up $452 million. Now, withFICO Insurance Fraud Manager 3.3, insurers have abetter way to fight back.” FICO Insurance FraudManager 3.3 boasts the first fully integrated linkanalysis capability with an insurance fraud application.Insurers who previously had to configure separate linkanalysis tools can now save time and improve resultswith an easy-to-use solution preconfigured to usehealth care claims data. 3
    • With FICO Insurance Fraud Manager 3.3, insurers caninvestigate organized fraud rings using thevisualization capabilities of a proven link analysis toolset, and easily create displays that reveal connectionsbetween disparate claims, patients and providers."Integrating link analysis with Insurance FraudManagers powerful analytics and our advancedbusiness rules gives insurers three ways to combatfraud, waste and abuse," said James Evans, vicepresident of network and financial management atMcKesson Health Solutions, which provides InsuranceFraud Managers analytics to U.S. insurers via itsInvestiClaim® solution. "This triple protection givesinsurers a powerful tool for fighting fraud, waste andabuse." 4
    • The new facility model in FICO® Insurance FraudManager 3.3 scans enormous volumes of claims data forrecurring, suspicious activity at a hospital or anoutpatient provider. Telltale signs may include unusualscheduling with a single patient, unusually expensiveprocedures, and even such issues as patients beingdischarged and readmitted, which can indicateproblems with quality of care. Universal American,which piloted this model with FICO, received a 2012FICO Decision Management Award this month for its useof FICO Insurance Fraud Manager to control costs andprevent fraud losses. Universal American, a leadingprovider of health benefits to people with Medicare,has implemented the FICO Insurance Fraud Managersolution into their 5
    • claims workflow prior to payment, and integrated itwith their claims platform, Facets. "One key to successin stopping inappropriate billing is to identify such billsbefore they are paid," Tyrina Blomer, MedicareCompliance Officer at Universal American, said of theFICO Insurance Fraud Manager Solution. "We were ableto identify and prevent $6 million in inappropriatebilling over an 18-month period.” FICO Insurance FraudManager detects fraud, abuse and errors in health careclaims and identifies suspicious providers as soon asaberrant behavior patterns emerge. Providers canaccelerate claims processing while saving money byavoiding improper payments, increasing loss recoveryand correcting systemic vulnerabilities. Staffproductivity increases via the systems ability to 6
    • prioritize work, rank-ordering claims by mostegregious and most financially significant. FICOInsurance Fraud Manager now scores claims fromdoctors, ancillary providers, pharmacies and healthcare facilities, as well as detecting fraudulentpatterns associated with specific medical providers,pharmacies and dentists. About FICO FICO(NYSE:FICO) delivers superior predictive analyticssolutions that drive smarter decisions. Thecompanys groundbreaking use of mathematics topredict consumer behavior has transformedentire industries and revolutionized the way riskis managed and products are marketed. FICOsinnovative solutions include the FICO® Score — 7
    • the standard measure of consumer credit risk in theUnited States — along with industry-leading solutionsfor managing credit accounts, identifying andminimizing the impact of fraud, and customizingconsumer offers with pinpoint accuracy. Most of theworlds top banks, as well as leading insurers,retailers, pharmaceutical companies and governmentagencies, rely on FICO solutions to accelerate growth,control risk, boost profits and meet regulatory andcompetitive demands. FICO also helps millions ofindividuals manage their personal credit healththrough www.myFICO.com. Learn more atwww.fico.com. FICO: Make every decision count™. 8
    • For FICO news and media resources, visit www.fico.com/news.• Statement Concerning Forward-Looking Information Except for historical information contained herein, the statements contained in this news release that relate to FICO or its business are forward-looking statements within the meaning of the "safe harbor" provisions of the Private Securities Litigation Reform Act of 1995. These forward-looking statements are subject to risks and uncertainties that may cause actual results to differ materially, including the success of the Companys Decision Management strategy and reengineering plan, the maintenance of its existing relationships and ability to create new relationships with customers and key alliance 9
    • partners, its ability to continue to develop new andenhanced products and services, its ability to recruitand retain key technical and managerial personnel,competition, regulatory changes applicable to theuse of consumer credit and other data, the failure torealize the anticipated benefits of any acquisitions,continuing material adverse developments in globaleconomic conditions, and other risks described fromtime to time in FICOs SEC reports, including itsAnnual Report on Form 10-K for the year endedSeptember 30, 2011 and its last quarterly report onForm 10-Q for the period ended June 30, 2012. If anyof these risks or uncertainties materializes, FICOsresults could differ materially from its expectations. 10
    • FICO disclaims any intent or obligation to update these forward-looking statements. FICO and "Make every decision count" are trademarks or registered trademarks of Fair Isaac Corporation in the United States and in other countries.-SOURCE FICO 11