Insurance companies need to be constantly wary of fraudulent claims and abuse. Members may conceal pre-existing health conditions or include prior minor automobile damages in their claims. Providers may submit claims for services not performed, they may collude with members and providers and organized crime is known to stage automobile accidents. Fraud deterrence and abuse detection save insurers millions of dollars every year.
Predictive analytics models are capable of detecting subtle patterns of unusual activity, allowing insurers to improve detection of claim fraud and abuse by quickly detecting, documenting and expediting investigation of suspect providers, claimants and claim-level behavior.
A Claims Fraud Scoring engine and list generation capabilities actively deter fraud and hasten recovery. Providers can quickly and easily distribute greater numbers of better targeted verification letters that are fully detailed with relevant claim history and data.
Angoss software and solutions for claims fraud deterrence and abuse detection allow organizations to:
- Build models based on actual cases and anomaly detection models
- Proactively detect claims fraud for health, dental and prescription drug claims
- Identify new kinds of fraud—often before your organization is aware they have occurred
- Create prioritized claims lists and targeting tools that support effective fraud and abuse strategies focusing on providers, claimants and claims that are most likely abusing systems and programs
- Detect post-payment and pre-payment instances—enabling analysis of past incidents and automated detection of new claims