The platform addresses health care payment fraud, waste and abuse with out-of-the box adaptive predictive analytics. This platform helps healthcare payers improve multiple aspects of their operations, including claims processing, medical policy, provider contracts, network management and compliance.
The FICO Payment Integrity Platform brings to bear three technologies for identifying potential claims irregularities, enabling corrective action to be taken before claims are paid. Adaptive predictive analytics find emerging fraud trends based on multi-faceted analysis of claims, providers and procedures. Link analysis looks for common data elements across claims. Business rules, authored by business users in FICO Blaze Advisor business rules management system, can identify problems based on known patterns and/or perform pre-processing on claims to highlight areas for analytic investigation.
Healthcare payers also have the option to access the FICO Payment Integrity Platform through a secure analytics as a service option. Payers submit their claims to FICO; the Payment Integrity Platform then analyzes the claims and returns the scored results with contextual reasons for high scores.
FICO is an analytics software company, helping businesses in more than 90 countries. Their products include the FICO Score, the standard measure of consumer credit risk in the US. FICO solutions leverage open-source standards and cloud computing to maximize flexibility and speed deployment.
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