FICO Launches Payment Integrity Platform to Slash Fraud in Health Care Insurance
FICO is showcasing the Payment Integrity Platform at the
The FICO Payment Integrity Platform brings to bear three technologies for identifying potential claims irregularities, enabling corrective action to be taken before claims are paid. Adaptive predictive analytics find emerging fraud trends based on multi-faceted analysis of claims, providers and procedures. Link analysis looks for common data elements across claims. Business rules, authored by business users in FICO® Blaze Advisor® business rules management system, can identify problems based on known patterns and/or perform pre-processing on claims to highlight areas for analytic investigation.
"Business rules identify black-and-white cases, whereas analytics deal with uncertainties," said
The FICO Payment Integrity Platform's out-of-the-box analytics enable payers to perform fingertip data mining with a single click — no SQL programming skill or analytic expertise is required. With a customizable claim review workflow system, high scoring claims can be reviewed and decisioned in as little as 30 seconds, with the decision results fed back into the claims processing system to be denied or held for further investigation. In addition, fraud rings can be detected with link analysis, an integral component of the Payment Integrity Platform. The enterprise-class platform can handle medical, pharmacy, dental and facility claims, and can process hundreds of millions of claim lines for provider scoring in a single day.
Healthcare payers also have the option to access the FICO Payment Integrity Platform through a secure analytics as a service option. Payers submit their claims to FICO; the Payment Integrity Platform then analyzes the claims and returns the scored results with contextual reasons for high scores.
"With this unique service, the user doesn't need to install or manage any software," said Schreiber. "It's ideal for smaller and medium-size payers who want the power of advanced predictive analytics at a lower cost. FICO pioneered this kind of service with credit bureau scoring, and we've now extended it into insurance claims analytics."
"We've noted FWA solutions addressing evolving threats with increased accuracy, adaptability and cost-effectiveness," said
About FICO
FICO (NYSE: FICO) is a leading analytics software company, helping businesses in 90+ countries make better decisions that drive higher levels of growth, profitability and customer satisfaction. The company's groundbreaking use of Big Data and mathematical algorithms to predict consumer behavior has transformed entire industries. FICO provides analytics software and tools used across multiple industries to manage risk, fight fraud, build more profitable customer relationships, optimize operations and meet strict government regulations. Many of our products reach industry-wide adoption. These include the FICO® Score, the standard measure of consumer credit risk in
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[i] IDC MarketScape: U.S. Healthcare Payer Fraud, Waste, and Abuse Solutions 2014 Vendor Analysis,"
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