Healthcare fraud

Financial Crime 4 марта 2015, 17:12

Proven analytics for pre-pay and post-pay initiatives in government healthcare.

We provide Government Healthcare programs with leading-edge social network analytics and predictive analytics to achieve a game-changing boost to the effectiveness of pre-pay and post-pay program integrity initiatives.
Our NetReveal® solution can operate in real-time to stop the cycle of “pay and chase” by blocking the payment of suspicious claims before the check is paid. The solution considers every claim in the context of the history of the beneficiary and providers and takes into account any relationship to other parties. Not only are current and future claims stopped, but the behavior is automatically identified by the solution, allowing easy post-pay recovery of previous instances.
We are helping our clients to achieve unrivalled improvements both in the total volume of aberrant claims detected as well as in the accuracy of detection (reduction of false positives). 

NetReveal has been proven to:

– Provide holistic protection by detecting fraud, waste, and abuse that happened in the past (post-pay) as well as preventing it going forward (pre-pay);
– Allow all program integrity efforts to be consolidated into a single intuitive case management and fraud detection solution that presents a holistic risk-profile for every claim, provider, and recipient;
– Maintain prompt payments – low risk providers and claims are able to be paid quickly, while resources can be focused on the highest risk cases via automated prioritization;
– Prevent fraudulent and improper payments – risk assess every claim in real-time through integration with MMIS;
– Automatically search for patterns of relationships, changes, and abnormalities in provider billing behavior to identify suspicious activity;
– Risk assess every new provider at enrollment – take into account complex and hidden relationships to previously known actors;
– Reduce time spent on investigations – using intuitive graphical tools and automatically generated case packs;
– Enable the execution and measurement of strategic campaigns – including education, behavioral change and deterrent campaigns.