FICO (NYSE:FICO), the leading provider of analytics and decision management technology, today announced the general availability of FICO™ Insurance Fraud Manager 3.1. With this newest version, FICO continues to build upon and strengthen its proven solution for detecting healthcare claim fraud, abuse and errors before claims are paid, and also for identifying suspicious providers as soon as aberrant patterns emerge. The latest release offers improved predictive power to help healthcare payers avoid fraud losses while accelerating the throughput of legitimate claims.
“US health insurers have been challenged to develop intra-enterprise fraud management frameworks, but are ill-prepared to participate in a collaborative, external model of fraud management”
Users of FICO Insurance Fraud Manager (IFM) report ROI ratios of as much as ten to one in averted and recovered fraud losses. Release 3.1 improves upon previous versions by expanding upon the medical and pharmacy claims analyses power to include dental claims. The 3.1 release also identifies patients who may need to be restricted to specific pharmacies and/or providers in order to prevent abuse.
Healthcare insurance fraud accounts for between three and ten percent of all healthcare insurance transactions, costing the industry — and, ultimately, consumers — an estimated $200-600 billion a year in the US alone. It is a major contributor to the high cost of healthcare.
Under regulatory pressure to process and pay claims within specific time frames, payers are often unable to detect fraud or errors until after a claim has been paid, then must expend significant resource trying to recover the payment. FICO Insurance Fraud Manager helps overcome the "pay and chase" syndrome, applying advanced predictive analytics to detect fraud earlier in the process. At the same time, it speeds the processing of good claims and helps payers comply with mandated payment timetables.
"The ability to do pre-payment scoring on a wider range of claiming entities means that payers will be able to detect more potential fraud and prevent larger losses," said Dr. Andrea Allmon, product director at FICO. "FICO's predictive analytics have proven far more effective than rules-based methods in early detection of sophisticated fraud schemes."
In addition to powerful claim and provider-level detection analytics, FICO™ Insurance Fraud Manager 3.1 includes a new user interface that makes it easy for users to access and share information across the organization; a comprehensive investigative case management tool; extensive reporting and analyses with intuitive drill-downs to supporting level detail; and an evidence locker for fraud investigations.
"US health insurers have been challenged to develop intra-enterprise fraud management frameworks, but are ill-prepared to participate in a collaborative, external model of fraud management," said Maureen O'Neil, principal research analyst, Gartner. "An integrated fraud management system is essential to conduct effective analysis, improve coordination, share information and leverage resources to gain position against healthcare fraudsters."
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