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

Q

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

U

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

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