Medical billing and healthcare fraud detection For insurance providers in workers' comp, private health care and automotive lines
RiskShield helps insurance companies focus on suspicious claims, whereas the claims perceived by the software as unsuspicious can directly be settled without wasting time and effort.
Insurance companies around the world today face the problem of how to deal with insurance fraud appropriately - in particular medical billing fraud. The aim is to present sophisticated claims investigators with a reduced number of highly suspicious claims for manual review. The incoming medical billing claims are analyzed to automatically extract claims that represent potential fraudulent activity or improper medical coding.
RiskShield assesses any fraud risk of individual incoming medical billing claims in real-time in matter of milliseconds and works transparently in the background. Upon receipt of a medical billing claim, the claims management system forwards it to RiskShield. The system uses rule sets and dynamic intelligent profiling to detect fraud patterns. Furthermore, RiskShield scores the medical providers based on the number of suspicious claims in which they are involved so that special attention can be given depending on their ranking.
- Advanced analytics
Unleash the value of advanced analytics to understand the costs of risks by using predictive modeling, simulations and data visualization tools.
- Transparent decision logic
Use easy to understand and user-friendly decision algorithms that can quickly adapt to new modus operandi of fraudsters.
- Stop known fraud patterns
Identify improper medical coding such as up-coding, unbundling and duplication of bills and stop payments to avoid fraud losses.
- Automated link detection
Identify and link similar shared indicators between people, addresses, phone numbers and objects automatically.
- Predictive analytics
Discover new trends and unknown fraud typologies by using advanced intelligent technology and data visualization tools.
- Business Intelligence
Dig into detailed information and conduct searches through recent alert activities, identify trends and evaluate statistics using this powerful visualization tool.
- Flexible integration
Integrate into the existing claims handling environment without impacting the IT systems with open and highly configurable interfaces.
- Social Network analysis
Visually interact with data and analyze alerts and claims to find any social links such as addresses, phone numbers, vehicle identification numbers and more.
- Case investigation
Streamline alerts and case investigations with an integration case management tool to manage your information in any form, from any source, all in one single environment.
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