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Slide 1: IBM Sales and Distribution Solution Brief Healthcare payers Fraud and abuse management for payers Prevent and detect fraudulent claims To uncover fraudulent and abusive behavior, investigators must sort through millions of individual claims to find suspicious behavior, often relying on a pay-and-chase strategy—pursuing cases after claims have already been paid. IBM has worked closely with healthcare investigators to develop the fraud and abuse management solution for payers with both proactive and retrospective detection capabilities. Highlights ● Support a diverse range of fraud investigation before and after claims payment Sort millions of claims in minutes and rank providers by degree of potentially abusive behavior Pinpoint claims most likely to be fraudulent or erroneous with advanced algorithms and analytical models Achieve rapid return on investment by enabling investigators and auditors to become more productive ● A sophisticated, comprehensive solution Detecting suspicious claims activity—such as billing for services not performed, billing more expensive claims than the actual service rendered, overprescribing tests and medications, and requiring tests and procedures that are not medically necessary—is a difficult dataintensive task. The fraud and abuse management solution for payers from IBM supports a diverse range of fraud investigation both before and after claims payment, including prevention, investigation, detection and settlement. The solution can help you transform your fraud and abuse management strategy by analyzing claims data using prebuilt fraud detection models designed for the healthcare industry. These models have been developed in conjunction with fraud investigators working in the field, and include an updated library of 9,000 risk indicators that can be used like building blocks to build new models or change existing ones. Advanced algorithms developed by IBM Research can help pinpoint claims most likely to be fraudulent or erroneous. Our analytical techniques include evaluating nonstandard claims submissions and statistical outliers, identifying patterns of abusive claims submissions and defining new provider segments to find previously unknown patterns of ● ●
Slide 2: behavior. Using a combination of data mining capabilities and graphical reporting tools, the solution can help identify potentially fraudulent and abusive behavior before a claim is paid or retrospectively analyze providers’ past behaviors to flag suspicious patterns more effectively than the traditional manual process. © Copyright IBM Corporation 2010 Reduce wrongful payments and increase productivity Without the tools to systematically and scientifically uncover suspicious claims, investigators must rely on tips from fraud hotlines, or use spreadsheets and database queries to perform relatively simple analysis. The fraud and abuse management solution can allow them to sort millions of claims in minutes, and then rank providers by degree of potentially abusive behavior. This can help speed and extend the ability to recover mistakenly paid claims and reduce wrongful medical payments. Our approach to fraud and abuse detection helps enable investigators and auditors to become more productive, handling broader caseloads by automating processes previously conducted manually. Increased productivity can lead to enough accurately identified suspicious claims to help your organization achieve a rapid return on investment. While some of the business requirements may differ, our solution can also address the needs of public payer plans, such as Medicaid, to help recoup dollars wrongly billed to the system. IBM Corporation Route 100 Somers, NY 10589 Produced in the United States of America May 2010 All Rights Reserved IBM, the IBM logo and ibm.com are trademarks or registered trademarks of International Business Machines Corporation in the United States, other countries, or both. If these and other IBM trademarked terms are marked on their first occurrence in this information with a trademark symbol (® or ™), these symbols indicate U.S. registered or common law trademarks owned by IBM at the time this information was published. Such trademarks may also be registered or common law trademarks in other countries. A current list of IBM trademarks is available on the Web at “Copyright and trademark information” at ibm.com/legal/copytrade.shtml Other company, product or service names may be trademarks or service marks of others. Please Recycle Transform fraud identification with IBM Collaboration with healthcare payers and our deep involvement with user groups allow us to offer you a fraud and abuse solution that can evolve as your business needs change. Our fraud and abuse management offering currently used by 30 public and private sector clients to identify and pursue suspicious claims. IBM brings together industry and process expertise, systems and business performance software, and our deep computing and advanced analytics capabilities to tackle your business challenges. For more information To learn more about the fraud and abuse management solution for payers, please contact your IBM representative or IBM Business Partner, or visit: ibm.com/healthcare HHS03005-USEN-00