New technology helps companies identify health insurance fraud
A Minneapolis, Minn., company has announced the general availability of a product to help target health insurance fraud.
FICO, a provider of analytics and decision management technology, said its Insurance Fraud Manager (IFM) 3 uses real-time predictive analytics to find patterns of fraud and abuse before payments are made, significantly reducing the costs of fraud by enabling insurers to better avoid paying fraudulent claims.
The company said the current “pay and chase” model, where insurers pay claims that may appear fraudulent to comply with government regulated timetables and later attempt to reclaim those funds, is “not a winning proposition for healthcare insurance companies.”
FICO said its IFM 3 leverages a predictive analytics model – in contrast to rules-based systems that power most insurance industry fraud detection systems today – to identify aberrant data patterns indicating fraud earlier in the claims payment process and provide proof of fraud before payment is required by law.
An earlier version of FICO’s IFM was used by Pittsburgh, Pa.-based Highmark, which identified 83 new fraud cases within the first few months of using the product, with the average dollar value per case exceeding the total price of the software for one year, according to both companies.


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