Fraud, Abuse And Waste


Due to the large volume of claim transactions coupled with the shrinking amount of time allowed for payment, the health care industry is especially susceptible to Fraud & Abuse. Federal health programs, as well as many states, have recognized the need for strong anti-fraud controls within the health insurance industry, and have mandated that those controls be put into place. Ideally, it is best to audit all claims one-by-one carefully. Auditing all claims is not feasible by any practical means. Various analytic techniques can be employed in developing audit short lists. Visual Intelligence offers now products and services based on data mining and visualization technologies designed to accelerate detection, recovery, and preventing overpayments as a result of fraud & abuse. Fraud&AbuseVIews screens medical and pharmacy claims to uncover suspicious patterns based on known rules as well as ad-hoc analyses. The application used comprehensive rules-based logic and statistical algorithms that flags providers and members who differ dramatically from history or peer-group norms. Leads generated by Fraud&AbuseVIews serve as a powerful starting point for initiating a fraud case, recovering funds or recommending claims editing improvements.


Fraud & abuse dynamic reporting dashboards through retrospective and proactive data mining business intelligence and analytics GeoAnalytics patterns for traffic and fraudulent cluster identification Dynamic reports revealing claims containing falsified procedure codes, services not rendered, upcoding, over-utilization and other common fraud tactics found across healthcare providers–covering professional, facility, pharmacy and dental types. Flags aberrant billing patterns and looks for suspicious relationships in your claim, member and provider data. Screens as many conditions as possible, helping you maximize your funds recovery processes


Healthcare fraud detection requires compilation of potentially huge data, involving complex computation and sorting operations. Fraudulent entities also adapt quickly to the rules that are created to detect fraud. Traditional approach is to use siloed datamarts, dimensional OLAP cubes or canned reports for known patterns. VI’s Fraud&AbuseVIews connects to all internal data sources - transactional, data warehouse, ODS and create investigative reports at a speed that surpasses the traditional approach. The questions generated by these reports are answered instantly and the investigators can quickly detect fraudulent outliers beyond the known rules, keeping pace with the ongoing creativity of those who commit fraud.


Fraud and Abuse Departments, Investigative Units tea, informatics analysts