Fraud, waste and abuse cost the health care industry billions of dollars each year. And health payers pass losses on to consumers in the form of higher premiums. Money lost to fraud and abuse is money that can’t be spent on improving the quality of care for those incurring valid expenses. Unfortunately, fraud often isn’t discovered until after claims are paid – and recovery of funds is unlikely. The SAS Fraud Framework for Health Care can help.
Detect more fraudulent activity.
By inserting analytical models into the process, in addition to rules engines, you can spot more fraudulent activity than ever before. Process all data (not just a sample) through rules and analytical models. Use customized models to detect previously unknown schemes. And spot linked entities and crime rings, which can help stem larger losses.
Reduce false positives and boost efficiency.
Gain real-time access to information by inserting analytical models into your process workflow. Apply risk-based scoring to model output before it goes to investigators, so you can ensure that valuable investigative resources are working on the highest profile cases. And by improving the efficiency of investigations, you will free investigators to work on more cases than ever before.
Reduce losses while increasing recoveries.
Use online real-time scoring to prevent fraud before claims are paid. Detect loss padding in similar claims using anomaly and loss comparisons. Identify repeat offenders and score incoming data more accurately by searching databases of known fraudsters and recording outcomes, claims settlement amounts, referrals and suspects for future reference. And focus investigations on higher-value networks and alerts by using risk- and value-based scoring models.
Gain a consolidated view of fraud risk.
Continually improve models and adapt the system to address changes in fraud trends. Better understand new threats and prevent big losses early using social network diagrams and sophisticated data mining capabilities.
- Fraud data management
- Rule and analytic model management
- Detection and alert generation
- Alert management
- Social network analysis
- Optional integrated case management solution
- Analytic model-ready
- Hosting and analytical services
With this modeling approach, our accuracy is much, much higher ... We've also decreased the time to create a model from weeks to just a few hours.