Recognize the many faces of fraud waste and abuse


IntelliPayer Fraud

IntelliPayer Fraud module is an intelligent fraud, abuse and waste analytics solution using which payers can analyze and design fraud scenarios, scorecards and transaction scanners for reducing wasteful spending. Using integrated data mining and statistical techniques in massive data sets from internal and external sources in real-time; our solution facilitates accurate fraud detection and prevention management across various functional areas of healthcare industry.

Business Challenges


Healthcare companies face unique challenges in controlling cost and preventing losses proactively. Fraud is a major contributor to loss in this industry. Global healthcare fraud has taken on several pretenses:


Assess payment risk associated with each provider

Over-utilization of services in very short time windows

Misrepresenting non-covered treatments as medically necessary covered treatments

Billing for more expensive services or procedures

False diagnoses, treatment and medical histories

Key Features

Integrated fraud and waste management solution

Complete solution to fight fraud, reduce waste and mitigate risk

Clinical review and validation of suspect billing activity

Analyze large volumes of historic claims data to identify irregular billing pattern

Predictive analytics, link-analysis and multi-variant models

Analytics model to reveal connections among entities to expose organized fraud rings

Profiling and scoring of high-risk providers and fraud schemes

Identify high-risk providers and suspicious claims using data mining, predictive analytics, and fraud scoring

Mine data to reveal possible fraud, and abuse

Mine data to detect hidden patterns and relationships that lead to potential waste, fraud and abuse

Detection and generation of fraudulent alert

Detect and generate fraudulent alert based on a calculated propensity for aberrant billing

Business Benefits

IntelliPayer Fraud analytics module enables payers to measure and improve quality of care, manage medical costs and improve payment accuracy.


Detect fraud, waste and abuse

Early detection of fraud, waste and abuse incidents


Prevent fraudulent claim settlement

Prevent fraudulent claim settlement by using online real-time scoring

Lower fraud losses

Lower your losses and increase recoveries by detecting fraud using anomaly and loss comparisons


Reveal possible fraud, and abuse

Uncover hidden trends and patterns in large amounts data to detect fraud in near real time

Find the solution that meets your need

GETTING STARTED

From member growth and retention to medical cost management, IntelliPayer is opening up other avenues and opportunities in healthcare, which includes combating fraud, driving product design, and strengthening quality of service delivery etc.

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