Integrated analytics help identify 30 to 40 percent more payment irregularities than traditional rules-based systems.
FICO introduced the FICO® Payment Integrity Platform, which addresses health care payment fraud, waste and abuse with out-of-the box adaptive predictive analytics. This platform helps healthcare payers improve multiple aspects of their operations, including claims processing, medical policy, provider contracts, network management and compliance. With its integrated analytics and business rules technologies, the FICO Payment Integrity Platform can identify 30-40 percent more payment irregularities than systems based on business rules alone.
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 Russ Schreiber, vice president of insurance solutions at FICO. “Together, they offer the best way to reduce the tens of billions of dollars lost to health care fraud, waste and abuse each year in the US alone. Part of the power in the FICO Payment Integrity Platform is that business users can quickly write and change their own rules without the need for IT support, as they spot new trends or need to implement new procedures. This is definitely the easiest to use and most flexible solution on the market.”
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.
Source: FICO Press Release