IBM Helps Health Care Insurance Companies Fight Fraud With Advanced Analytics

IBM Helps Health Care Insurance Companies Fight Fraud With Advanced Analytics

IBM’s (NYSE: IBM) Fraud and Abuse Management System, which provides detection capabilities to help health care payers identify questionable claims and develop cases for investigation, is being enhanced to provide even more efficient and cost-effective ways to tackle health care insurance claim fraud, waste and abuse.

The system, which was developed by IBM researchers and consultants in collaboration with leading health care insurance companies, is now being offered with an automated analysis capability, which can be added onto the client’s system to reduce the cycle time for claims investigators, and in an “on-demand” model. Clients using the on-demand version have their analyses run on IBM computers and are charged based on the amount of claims processed and number of medical specialties being analyzed.

According to estimates from the federal government and issues-based groups such as the National Health Care Anti-Fraud Association (NHCAA), as much as 10 percent of all health care expenditures in the United States, or $100 billion dollars, may be lost each year to fraud, waste and abuse. Prevention and recovery of only a fraction of this $100 billion represents both a significant ROI opportunity and a competitive advantage.

IBM’s Fraud and Abuse Management System supports the various aspects of fraud investigation and management, including prevention, investigation, detection and settlement. Using a unique combination of data mining capabilities, visualization techniques and reporting tools, the system can identify potentially fraudulent and abusive behavior before a claim is paid, or retrospectively analyze providers’ past behaviors to flag suspicious patterns. The system far outpaces traditional manual processes by sorting through tens of thousands of providers and tens of millions of claims in minutes — and then ranking providers as to their degree of potentially abusive/questionable behavior.

Read the complete Press Release