Solution Brief
Payment integrity for health care
Uncover suspicious health claims faster, minimize losses and protect resources.
SAS facts
- 100% of Fortune Global 500 health and life sciences companies are SAS customers.
- SAS is used by all US state governments and provides advanced analytics support to 1,700 health and social services customers worldwide.
- SAS provides data and AI support for both public and private health care initiatives across the globe.
The issue
Cost containment pressures are mounting for payers as health care markets evolve, and as the integration between commercial and government health care systems increases. The increased integration between health care payers, direct care provider networks, pharmacies and pharmacy benefit managers further complicates cost containment efforts. Multiple internal and third-party automated systems are producing more data than ever, but integrating data to provide useful analytical insights for users across the organization remains difficult.
Managing health care costs now encompasses a range of organizational challenges and risks, including payment integrity issues, regulatory compliance pressures, fraud detection, abuse prevention and the challenge of limited resources. Meanwhile, business information users demand faster data analytics and deeper insights to support cost containment efforts. The analytical needs of a variety of organizational users across health care also continue to change in response to digital transformation, rapid expansion of lower-cost cloud services and advancing electronic health record (EHR) and Internet of Things (IoT) technologies and the adoption of generative AI.
The challenge
Data silos
It’s difficult to combine all data sources into a usable format. SAS collects and integrates diverse data from systems and program silos, then applies robust advanced analytics and visualizations to detect and prevent fraud, waste and abuse (FWA) faster.
Limited resources
Small teams of investigators struggle to manage errors, identify fraud schemes and review cases efficiently. SAS streamlines the process by combining data into a unified platform for analysis, prioritizes alerts and routes them to investigators and provides advanced case management tools to maximize productivity.
Cost containment
Increased fraud, waste and abuse can lead to negative financial impacts. SAS incorporates multiple techniques – like automated business rules, multivariate anomaly detection, predictive modeling, text mining and network link analysis – to uncover fraud and improper payments before they occur.
Complex fraud schemes
Adapting quickly to digital transformation and emerging technologies like generative AI to increase risks creates a potential for errors and new fraud schemes. SAS uses data and AI to scan growing volumes of claims to spot anomalies, triage and prioritize cases and uncover suspicious activity for proactive investigation.
AI and regulatory compliance
AI regulations impacting health care payment integrity continue to grow and evolve. SAS equips teams to proactively address fraud with advanced analytics and with a cloud-based solution that enables automated updates with little input required.
(Enable an equitable data exchange; Derive analytical insights; Enhance financial and operational efficiencies; Effectively tailor care services; Improve health quality measures )
Our approach
Our comprehensive solution from SAS helps you detect and prevent health care fraud, waste and abuse faster through automation, and manage payment integrity issues from every angle through:
Get faster, better insights with a consolidated view of all types of data
Integrate data from different sources into a unified platform, covering the entire data and AI life cycle, helping you increase detection rates, decrease false positive alerts and make trustworthy decisions.
Detect and prevent FWA faster
Uncover more fraud faster with advanced analytics with embedded AI and machine learning algorithms, combined with other techniques like business rules, outlier analysis, peer grouping, database searches, risk scoring, text mining and network link analysis.
Automated investigations
SAS offers a comprehensive alert generation process, using predictive modeling, automated business rules and AI-driven alert prioritization for investigators.
Anomaly detection
Apply anomaly detection using over 1,400 health care-specific scenarios, revealing unusual behaviors and identifying high-risk claims and claim lines, including medically unlikely edits.
Social network analysis
Identify linkages among claims faster with a unified visualization interface and build social networks to gain a holistic view of fraud risk and discrepancies.
Trusted analytics for everyone
Access to analytic insights for all users across the health ecosystem. Trusted insights that improve care, policy and member health.
SAS difference
With our purpose-built solutions, SAS can help solve your most complex problems across medical cost management; risk adjustment; fraud, waste, abuse and error; outcome-based analytics; and value-based payments. SAS helps you identify and investigate fraud and make higher-value referrals to regulators and law enforcement.
Through SAS Payment Integrity for Health Care, large insurers, pharmacy benefit managers and government agencies can strengthen oversight across the entire program life cycle. From eligibility and enrollment to managed care monitoring, prepayment prevention and post-payment recovery, SAS ensures payment accuracy and program integrity at every stage.
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Identify linkages among claims, patients, providers and facilities – then identify suspicious behaviors within these networks.
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Generate prioritized alerts and create customized reports to predict, prevent and manage payment integrity issues.
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Create custom views faster, which saves time for internal resources, to help quantify impact and ROI for leadership to continue to invest in resources. Customizable dashboards allow you to quantify violations and associated costs.