Detect and prevent health care fraud, waste and abuse at every stage of the claims process, and stop improper payments before claims are paid. SAS Detection and Investigation for Health Care provides an end-to-end framework for ensuring payment integrity, with components for fraud detection, alert management and case handling.
Detect more fraud, reduce your losses and optimize payment integrity.
Spot more payment integrity breaches than ever before with a robust fraud analytics engine that processes all data (not just a sample) in real time or in batch. Running on the powerful SAS Platform, the solution uses advanced analytics with embedded artificial intelligence (AI) and machine learning algorithms, combined with other techniques – business rules, outlier analysis, text mining, database searches, exception reporting, network link analysis, etc. – to uncover more suspicious activity with greater accuracy.
Gain a consolidated view of fraud risk.
Identify linkages among seemingly unrelated claims with a unique visualization interface that lets you go beyond individual and account views to analyze all related activities and relationships at a network dimension. Social network diagrams and sophisticated data mining capabilities give you a better understanding of new threats, enabling you to prevent big losses early. And you can stay on top of changes in payment and cost containment trends by continually improving models and adapting the system.
Reduce false positives while boosting efficiency.
The solution applies risk- and value-based scoring models to accurately score and prioritize alerts before they go to analysts, clinicians or investigators. With the time saved, valuable personnel can work more cases with greater efficiency and focus on higher-value networks that generate a better ROI. More accurate scoring also means fewer false positives – and that translates to less customer inconvenience and greater customer satisfaction.
- Fraud data management. Includes a health-care specific fraud, waste and abuse data model that consolidates data from internal and external sources – claims systems, watch lists, third parties, unstructured text, etc. – and seamlessly integrates existing payment integrity solutions.
- Advanced analytics and embedded AI. Provides a broad set of advanced analytic and AI techniques, including modern statistical, machine learning, deep learning and text analytics algorithms.
- Rule and analytic model management. Includes prepackaged heuristic rules, anomaly detection and predictive models, and lets you create and logically manage business rules, analytic models, alerts and watch lists.
- Detection and alert generation. Calculates the propensity for fraud at first submission with a scoring engine that combines business rules, anomaly detection and advanced analytics; then rescores claims at each processing stage as new claims data is captured.
- Alert management. Combines alerts from multiple monitoring systems and associates them with common individuals for a more complete view of risk for individuals or groups.
- Social network analysis. Provides a unique visualization interface that lets you go beyond transaction and account views to analyze related activities and relationships at a network dimension.
- Search and discovery. Lets you perform free-text, field-based or geospatial searches across all data (internal and external), and refine searches using interactive filters.
- Intelligent case management. Systematically facilitates operational, clinical or investigative reviews using a configurable workflow, and stores all information pertinent to a case.
- Flexible deployment options. Enables you to choose the deployment option that works best for you – complete hosting by SAS, deployment at your site or a combination of the two.
This solution runs on SAS® Viya®, which has the breadth and depth to conquer any analytics challenge, from experimental to mission critical. SAS Viya extends the SAS Platform to enable everyone – data scientists, business analysts, developers and executives alike – to collaborate and realize innovative results faster.
Learn more in the SAS Detection and Investigation for Health Care product brief.
Find out how you can best detect, prevent and manage health care claims fraud.
Find out what you should do about eligibility fraud.