Precision Fraud, Waste and Abuse Detection™
Flag waste at the point of decision and fraud and abuse before claims are paid
Predictive Machine Intelligence to Detect and Prevent Fraud, Waste and Abuse in Real-Time
Precision Fraud, Waste, and Abuse Detection augments the work of quality and value improvement teams through real-time detection of low-value care. This solution uses proprietary advances in machine learning to detect utilization that deviates along multiple dimensions and scales from value-based care patterns by using the maximum available information about members, providers and evolving care patterns. The solution flags waste at the point of decision and fraud and abuse during claims processing before payments are made.
Key Features
Prevent Delivery and Payment of Low-Value Care
Flag low-value care in real-time at the point of decision and surface wasteful care before claims are paid
Stay Ahead of Emerging FWA Paradigms
Continuously self-learn changing care patterns in order to identify evolving patterns of fraud, waste and abuse
Highlight Opportunities for Value Improvement
Aggregate analyses of flagged low-value care patterns to identify areas for organization-wide value improvement
Minimize False Positives and Negatives
Maintain a nuanced view through high-confidence anomaly detection across the full spectrum of claims