SAS^® for Health Insurance Fraud

Healthcare fraud costs the industry an estimated $45 billion to $150 billion each year. With those staggering figures translating into the recovery of only 10 cents of every fraudulent dollar identified, the healthcare industry is facing an urgent need to adopt more proactive and advanced analytic techniques in order to protect benefit premiums and to avoid passing along these potentially avoidable costs to consumers.

In the Spotlight Detecting Healthcare Fraud Through Cutting-Edge Analytics On-Demand Webcast

While the problem is widely recognized, there hasn't been an effective solution for identifying and preventing health insurance fraud. Until now.

SAS for Health Insurance Fraud goes beyond traditional rules-based fraud detection solutions to offer advanced analytics that enable you to make predictive, accurate claims decisions before claims are paid. The solution integrates easily with your claims payment processes to improve recovery and prosecution efforts.

SAS for Health Insurance Fraud supports a four-part process flow:

Data acquisition and management
The SAS solution accesses a variety of data sources – including medical and pharmaceutical claims, provider enrollment information and more – to uncover all leading indicators of fraudulent activity. SAS can also access existing fraud recovery data marts so you can make use of information that is already available. All relevant data – regardless of the source – can then be combined into a data model for further exploration and analysis to uncover links and identify relationships between patients, providers and services.

Outlier exploration – fraudulent claims and provider analysis
The SAS solution drives proactive investigations by automatically uncovering previously undetected relationships. This knowledge can be used for predictive modeling techniques, neural networking and other statistical procedures, and then reported in a variety of ways depending on user needs.

Integration with claims payment process
The SAS solution uses predictive model scoring to help you identify suspicious patterns and links to submitted claims so you can slow the inappropriate disbursement of claims funds and focus on prosecution versus recovery efforts.

Recovery and prosecution
The SAS solution helps optimize the recovery and prosecution process by helping to deploy information investigators, determining the likelihood of recovery and raising alerts or flags where appropriate.