IBM Smarter Analytics Signature Solution for healthcare


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Learn how IBM Smarter Analytics is Signature Solution for healthcare, detecting and preventing healthcare fraud, waste and abuse. For more information on IBM Systems, visit

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IBM Smarter Analytics Signature Solution for healthcare

  1. 1. Solution Brief IBM Systems and Technology Group IBM Smarter Analytics Signature Solution for healthcare Detecting and preventing healthcare fraud, waste and abuse It is estimated that every year tens of billions of dollars are lost because of healthcare fraud, abuse and waste. Fraudulent claims are hidden among the hundreds of millions of claims submitted annually. Because healthcare organizations are under great pressure to pay claims quickly and overburdened investigators lack the resources and technology to identify and combat fraud effectively, costs from fraud and abuse continue to rise. Healthcare organizations and insurers need a new approach to fraud detection that can help uncover new fraudulent schemes, recognize patterns of non-compliant behavior and identify providers or consumers that are likely to commit fraud in the future. The IBM® Smarter Analytics Signature Solution for healthcare on IBM zEnterprise® uses sophisticated analytics to identify potentially fraudulent claims before payment and reduce the number of false claims paid. Methods of fraud, such as billing for more expensive services than those actually performed, or even conducting unnecessary medical procedures for the purpose of billing insurance, have become more sophisticated and costly to health plans. With the Smarter Analytics Signature Solution, health insurers can detect suspicious transactions before payment, minimize loss from overpayments, and recommend methods of intervention. Highlights: • Detect suspicious transactions • Analyze historical and real-time data • Integrate fraud detection with case management • Benefit from IBM software and IBM System z, optimized for healthcare fraud workloads
  2. 2. Solution Brief IBM Systems and Technology Group 2 The Smarter Analytics Signature Solution analyzes a range of behaviors simultaneously at both the claim and provider level to identify suspect behavior quickly. Retrospectively, it can analyze past behaviors to flag suspicious patterns. It replaces traditional manual processes by sorting through millions of claims in minutes and flagging potentially fraudulent, abusive or questionable behaviors. Because it can be integrated with your case management system, health plans can more effectively prioritize claims based on value, the likelihood of appeal and other factors. With the Smarter Analytics Signature Solution in place, you can move from post-payment analysis to pre-payment fraud detection without affecting efficiency and claims processing throughput, which can translate into fewer erroneous payments and a rapid return on your investment. Detect suspicious transactions To detect fraud, you need to determine what constitutes “normal” behavior versus those behaviors that are “different” or “bad.” Identifying how these “outliers” behave relative to other providers or consumers can help you identify fraudulent activities. If you can detect fraud before paying out funds, you can reduce recovery expenses for fraudulent claims. Before a claim is paid, the Smarter Analytics Signature Solution can identify potentially fraudulent and abusive behavior using a unique combination of fraud detection models that contain thousands of scheme classifications across more than 20 medical areas. The data mining, predictive analytics tools and reports allow you view a provider’s past behaviors, flag suspicious patterns and predict the likelihood of future fraud. Using the dashboard view, you can see summary data about your entire inventory of cases and comparative trends from fraud analyses. You also can view summary information on the results of fraud investigations including dollars saved, number of cases closed and other key performance indicators. Because the Smarter Analytics Signature Solution can identify multiple fraudulent behaviors and schemes simultaneously, it can significantly improve your fraud detection ratio. With the ability to drill down into detailed information on each provider or claim, antifraud investigators and auditors can zero in on questionable behavior and focus their attention on the most egregious offenders. Analyze historical and real-time data Once you have detected fraudulent schemes, patterns of non-compliant behavior or even criminal activity, the next step is to use analytics to identify others that are behaving like the identified “bad” provider or consumer. Advanced analytics capabilities built into the Smarter Analytics Signature Solution help you evaluate and analyze historical and real- time data. When you discover groups of providers or patients that are behaving in the same irregular way, and can predict who is likely to behave badly in the future, you can isolate the indicators that show whether or not a provider’s or consumer’s behavior is getting worse over time. The Smarter Analytics Signature Solution embeds advanced algorithms directly into business processes, which gives health insurers the ability to detect fraud in real time and before funds are paid. The solution actually “learns” from the latest data, which helps protect your organization from new approaches to fraud. Using sophisticated analytics, the solution recommends the most effective remedy for each case, which optimizes an organization’s resources. For example, the system might recommend that a simple letter requesting payment be sent to resolve one case, while recommending that a full investigation be opened in another case.
  3. 3. Solution Brief IBM Systems and Technology Group 3 Integrate fraud detection with case management Many US health plans use the zEnterprise system to support claims processing and adjudication. When your operational data and/or data warehouses are housed on IBM System z®, you can take advantage of workload-optimized fraud detection capabilities on zEnterprise. Running analytics in close proximity to related data avoids data proliferation across multiple systems and can enable faster response times with fewer compute resources, and reduce potential security exposures and outages. In addition, the data used for real-time analysis is more accurate, resulting in fewer “false positives.” In some cases, compliance issues can arise if claim payments are stopped without sufficient reason. Reducing false positives will significantly improve confidence in claims that are stopped for further investigation of potential fraud. This tight integration with transactional systems (where claims data and processes typically reside) can also produce performance benefits, better resource management and workload assessment. By integrating fraud detection with case management, you can more effectively prioritize claims based on value, the likelihood of appeal and other factors. You have the flexibility to move from post-payment analysis to pre- payment fraud detection without affecting efficiency and performance targets for claims adjudication rates. Additionally, when you deploy the Smarter Analytics Signature Solution on zEnterprise, you can incrementally enhance claims processes with predictive analytics building blocks, eliminating the need to extract, transform and load the data into yet another IT environment. Benefit from IBM software and System z, optimized for healthcare fraud workloads The Smarter Analytics Signature Solution is well integrated across all layers, embedding the industry-proven fraud detection models and capabilities of the IBM Fraud and Abuse Management System (FAMS). In addition, it brings the unique characteristics of healthcare fraud workloads together with IBM software and System z software for optimal performance. IBM SPSS® predictive analytics software and System z servers deliver a highly optimized analytics environment that can take advantage of new IBM DB2® on IBM z/OS® and SPSS Modeler functionality in close proximity to data that resides on System z. z/OS DB2 technologies for scoring and temporal data combined with SPSS scoring capabilities are a powerful combination. Models can be scored and updated in real time at the time of the transaction, allowing data from current transactions to be factored into the analysis along with historical data. Combining SPSS predictive analytics capabilities with System z means a higher percentage of fraudulent claims can be detected before payment without negatively impacting claims processing efficiency, which further reduces recovery costs. SPSS scoring algorithms perform mathematical calculations that require an advanced floating-point architecture. The zEnterprise system is designed to optimize this type of analytic computation with improved hardware, compilers and one of the industry’s fastest processors. The zEnterprise system supports clustering technologies that allow multiple servers to work together to provide 24-hour a day operations for years. Clustered servers can be miles apart, eliminating the possibility that your fraud and abuse solution will be unavailable because of local site problems, electrical disruptions or system maintenance. The Smarter Analytics Signature Solution is capable of dynamically moving applications across clustered systems to help ensure accessibility to the underlying data, so your staff remains productive without experiencing unplanned outages.
  4. 4. Solution Brief IBM Systems and Technology Group 4 ZSS03070-USEN-00 Please Recycle © Copyright IBM Corporation 2012 IBM Corporation System and Technology Group Route 100 Somers, NY 10589 Produced in the United States of America August 2012 IBM, the IBM logo,, System z, z/OS, zEnterprise, DB2, and SPSS are trademarks of International Business Machines Corp., registered in many jurisdictions worldwide. Other product and service names might be trademarks of IBM or other companies. A current list of IBM trademarks is available on the web at “Copyright and trademark information” at This document is current as of the initial date of publication and may be changed by IBM at any time. Not all offerings are available in every country in which IBM operates. THE INFORMATION IN THIS DOCUMENT IS PROVIDED “AS IS” WITHOUT ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING WITHOUT ANY WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND ANY WARRANTY OR CONDITION OF NON- INFRINGEMENT. IBM products are warranted according to the terms and conditions of the agreements under which they are provided. The System z environment is a world-class database and hardware platform that is optimized to deliver performance, flexibility and scalability for the most complex analytics applications. It can dynamically add capacity without major technology replacements or migrations. You can purchase additional capacity for deployment, without sacrificing data availability. A centralized environment can help eliminate unused capacity that is costly to purchase and difficult to manage. When you centralize your information infrastructure onto a single zEnterprise or cluster of System z servers, you can maximize your return on investment and ensure a cost- efficient infrastructure. With the robust, easy to scale and manage infrastructure, your fraud and abuse solution can remain accessible without compromising staff productivity. Together, the zEnterprise platform and SPSS predictive software make it possible for data from current transactions to be factored into analysis in real-time. Why IBM? IBM has worked with health plans for decades to develop and evolve an optimal approach to fraud detection. The Smarter Analytics Signature Solution builds on this proven experience and technology and is backed by a comprehensive array of data management and business analytics tools from IBM that take the guesswork out of making claims-related decisions. IBM offers a unique combination of business analytics products, solutions, services and experience that can help you develop a roadmap to create business value with analytics. IBM brings deep expertise in managing and integrating complex systems that has helped transform the world’s retail, financial services and energy industries. IBM also has broad experience in life sciences, bioinformatics and the full spectrum of healthcare disciplines. IBM has actively worked with governments to lay the foundations of a twenty-first century healthcare system. Together with its healthcare clients and partners, IBM is redefining value and success in healthcare and is helping to build a smarter healthcare industry. For more information To learn more about the IBM Smarter Analytics Signature Solution for healthcare please contact your IBM representative or IBM Business Partner, or visit: analytics/us/en/solutions/