SAS^® Fraud Framework for Health Care

Features

Fraud data management

• Consolidate historical data from internal and external sources – claims systems, watch lists, third parties, unstructured text, etc.
• Eliminate or reduce redundant or inconsistent data with the solution's built-in data quality tools.
• Seamlessly integrate the solution with your third-party fraud applications.

Rule and analytic model management

• Create and logically manage business rules, analytic models, alerts and known fraudster lists.
• Customize analytic models to identify fraud, waste and abuse not found by existing business rules.
• Easily manage the deployment, aggregation, scheduling, suppression and routing of similar rules across multiple factors, such as parties, data sources and business lines.
• Run groups of rules and models alone, in parallel or at different times (intraday, daily, weekly, monthly, etc.).

Detection and alert generation

• Calculate the propensity for fraud at first submission, then rescore claims at each processing stage as new claims data is captured. 
• Review claims early in the adjudication process so you can stop suspicious activity at the prepayment stage. 
• Incorporate fraud detection methods into the process at the most appropriate points – e.g., cases where anomaly detection scenarios may require data that is not available until later in the adjudication process.

Alert management

• Combine alerts from multiple monitoring systems, associate them with common individuals and gain a more complete perspective on the risk of particular individuals or groups.
• Prioritize the investigative order of alerts by scoring alerts in real time, based on the specific characteristics.
• Route alerts to appropriate team members based on user-set rules and requirements.
• View all evidence for each case via a dashboard that is customizable to your investigative unit's processes.

Social network analysis

• Go beyond transaction and account views to analyze related activities and relationships at a network dimension.
• Identify linkages among seemingly unrelated claims using a unique network visualization interface.
• Produce complete dossiers of networks surrounding a case and gain fast access to full details on all related parties and networks.
• Produce independent and combined fraud scores, so you can assess overall risk on a customer, claim or network basis.
• Increase investigator effectiveness by enabling investigators to merge and delete network entities, and add annotations (text and images) to specific entities in a network.
• View how activity in a network develops over a time horizon, using time slider functionality.

Optional integrated case management solution

• Systematically facilitate investigations using a configurable workflow.
• Store all information pertinent to a case, including detailed investigation information – e.g., interview notes and evidence for criminal or civil prosecution, restitution and collections.
• Assess overall fraud exposure, including losses due to fraud as well as fraud detected or prevented.

Analytic model-ready

• Provides prepackaged heuristic rules, anomaly detection and predictive models.
• Includes a health care-specific fraud, waste and abuse data model.
• Lets you harness the power of advanced analytics out of the box.

Hosting and analytical services

• Can be installed and administered at the SAS hosting site, which enables faster implementation (and faster ROI) while eliminating the need for payer staff to oversee the system. 
• Can be hosted at your site, in which case SAS Professional Services staff will assist with the implementation and provide knowledge transfer.