SAS^® Fraud Framework for Health Care

Health insurance fraud, waste and abuse cost the industry an estimated $45 billion to $150 billion each year. With those staggering figures translating into the recovery of only 10 cents of every fraudulent dollar identified, the industry is facing an urgent need to adopt more proactive and advanced analytic techniques in order to protect benefit premiums and to avoid passing along these potentially avoidable costs to consumers.

In the Spotlight Fixing Fraud(PDF) Richard J. Pro, Health Plans Principal in the SAS Health and Life Sciences Global Practice, discusses with Future Healthcare how billions of dollars lost to healthcare fraud each year can be stymied.

While the problem is widely recognized, there hasn't been an effective solution for identifying and preventing health insurance fraud. Until now. How the SAS® Fraud Framework for Health Care Can Help The SAS Fraud Framework for Health Care goes beyond traditional rules-based fraud detection to offer advanced analytics that enable you to make predictive, accurate claims decisions before claims are paid. In addition, the SAS Fraud Framework for Health Care integrates easily with your claims payment processes to improve recovery and prosecution efforts.

The framework includes components for:

Detection and Alert Generation
SAS provides solutions that:

• Enable the systematic detection of suspicious activity using a combination of different analytic techniques to determine the likelihood of health insurance claims fraud.
• Include a fraud scoring engine that is designed to detect fraud in medical, pharmaceutical and durable medical equipment claims and more, and can be extended easily to support other areas as needs arise.

• Assemble alerts from multiple monitoring systems, associate them with common individuals and provide investigators with a more complete perspective on the risk of a particular member or provider.
• Perform additional tasks, including:
  • Risk score calculation. Each alert generated is assigned a risk score based on the specific characteristics of the activity, with transparent reason codes.
  • Alert prioritization. Prioritizes and routes potentially fraudulent claims to appropriate team members, resulting in greater efficiency, increased detection rates and dramatically reduced false positive rates.
  • Work assignment. Organizations can route automated alert assignments to various investigators or analysts based on rules and requirements set by the user.

• Uncover previously hidden linkages between members, providers and suppliers that would otherwise go undetected.
• Detect and prevent fraud by going beyond single claim views to analyze all related activities and relationships between patients, providers, suppliers and services incurred.

Case Management
Case management capabilities from SAS let you:

• Systematically facilitate investigations and capture and display all information pertinent to a case.
• Store information regarding fraudulent activity, including interview notes and evidence needed for criminal or civil prosecution, restitution and collections.
• Access information on your organization's overall fraud exposure, including losses due to fraud as well as fraud detected or prevented.
• Facilitate assignment of cases to investigators.
• Configure workflows for the management and resolution of cases.

How the SAS^® Fraud Framework for Health Care Is Different

No other fraud solution provides the same level of detection, automation, ease of use and ROI for health insurance claims fraud. The SAS Fraud Framework for Health Care:

• Provides enhanced fraud detection and greater insight into health insurance claims fraud.
• Measures the likelihood of a claim being fraudulent at each stage of the claims process with an anti-fraud analytical engine that uses a combination of techniques to assign each claim a fraud score.
• Improves operational efficiency by creating alerts for suspicious claims and routing them to special investigation units where investigators can use case management tools to investigate rapidly before losses occur.
• Helps health insurers decrease fraud losses and increase recoveries without increasing team resources.
• Harnesses the power of world-class predictive modeling and delivers easy-to-use results to fraud investigators through point-and-click investigation screens.
• Uncovers collusion and multiparty fraud schemes using an intuitive, graphical fraud viewer.