Fraud Detection and Prevention
Prevent health insurance fraud before claims are paid
" SAS helped us implement robust health care fraud detection software within a 90 day time frame. The software is already helping to detect issues in pharmaceutical claims we're receiving. The SAS team has listened to and met all our needs and has worked well with our internal team."
— Mike Occhipinti
Director, Informatics
Business Intelligence and Data Management
Horizon BCBSNJ
How SAS® Can Help
Proactively uncovering health insurance fraud requires extensive data gathering and analysis, but such information is often difficult and time-consuming to obtain. With SAS, you can:
- Enhance information credibility by integrating disparate data sources and applying embedded data quality techniques.
- Find fraud before claims are paid using a hybrid of business rules, predictive analytics and social network analysis technology.
- Reduce false positives with a sophisticated fraud scoring engine.
- Improve investigator efficiency with advanced case management tools.
- Measure program performance by defining and monitoring key performance metrics.
How SAS® Is Different
Only SAS delivers a proven, hybrid analytic approach that ties together all the essential areas of health insurance fraud detection and prevention. With SAS, you get:
- Complete data management capabilities that include data integration, cleansing and aggregation.
- Detection and alert generation capabilities that detect suspicious activity using a combination of analytic techniques, and alert management capabilities that assemble alerts from multiple monitoring systems to enable prioritization of suspicious claims.
- Social network or link analysis that is incorporated into the priority score for fraud detection.
- The ability to customize and modify rules and models as needed.
- The ability to incorporate both structured and unstructured text data.
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Seamless integration with case management capabilities that provide a systematic means for capturing and displaying all relevant information.
Related Products and Solutions
The SAS® Fraud Framework for Health Care
Outright fraud costs the health care industry an estimated $70 billion each year. Only 10 percent of such fraud is ever detected, and only 10 cents of each fraudulent dollar billed is ever recovered. Health insurers pass these losses on to consumers in the form of higher premiums. In the case of self-funded plans, losses result in dollars intended for plan benefits never actually being available. That's why SAS developed the SAS Fraud Framework for Health Care to help health insurers detect and prevent both opportunistic and professional fraud within the health care claims process.
SAS® Enterprise Case Management
SAS Enterprise Case Management enforces best practices and proper gathering of evidence, and can greatly reduce the cost of investigations. The solution provides a structured environment for managing investigation workflows, attaching comments or documentation and recording financial information, such as exposures and losses. This gives investigators more power, flexibility and task automation, without having to rely on IT for support.
Ready to learn more?
Call us at 1-800-727-0025 (US and Canada) or request more information.
