IBM Sales and Distribution
Solution Brief
Highlights
● Support a diverse range of fraud
investigation before and after claims
payment
● Sort millions of claims in minutes and
rank providers by degree of potentially
abusive behavior
● Pinpoint claims most likely to be fraud-
ulent or erroneous with advanced algo-
rithms and analytical models
● Achieve rapid return on investment by
enabling investigators and auditors to
become more productive
Healthcare payers
Fraud and abuse
management for payers
Prevent and detect fraudulent claims
To uncover fraudulent and abusive behavior, investigators must sort
through millions of individual claims to find suspicious behavior, often
relying on a pay-and-chase strategy—pursuing cases after claims have
already been paid. IBM has worked closely with healthcare investiga-
tors to develop the fraud and abuse management solution for payers
with both proactive and retrospective detection capabilities.
A sophisticated, comprehensive solution
Detecting suspicious claims activity—such as billing for services not
performed, billing more expensive claims than the actual service ren-
dered, overprescribing tests and medications, and requiring tests and
procedures that are not medically necessary—is a difficult data-
intensive task. The fraud and abuse management solution for payers
from IBM supports a diverse range of fraud investigation both before
and after claims payment, including prevention, investigation, detec-
tion and settlement.
The solution can help you transform your fraud and abuse manage-
ment strategy by analyzing claims data using prebuilt fraud detection
models designed for the healthcare industry. These models have been
developed in conjunction with fraud investigators working in the field,
and include an updated library of 9,000 risk indicators that can be used
like building blocks to build new models or change existing ones.
Advanced algorithms developed by IBM Research can help pinpoint
claims most likely to be fraudulent or erroneous. Our analytical tech-
niques include evaluating nonstandard claims submissions and statisti-
cal outliers, identifying patterns of abusive claims submissions and
defining new provider segments to find previously unknown patterns of
behavior. Using a combination of data mining capabilities and graphi-
cal reporting tools, the solution can help identify potentially fraudulent
and abusive behavior before a claim is paid or retrospectively analyze
providers’ past behaviors to flag suspicious patterns more effectively
than the traditional manual process.
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Reduce wrongful payments and increase IBM Corporation

productivity
Without the tools to systematically and scientifically uncover suspi-
cious claims, investigators must rely on tips from fraud hotlines, or use
spreadsheets and database queries to perform relatively simple analysis.
The fraud and abuse management solution can allow them to sort mil-
lions of claims in minutes, and then rank providers by degree of poten-
tially abusive behavior. This can help speed and extend the ability to
recover mistakenly paid claims and reduce wrongful medical payments.
Our approach to fraud and abuse detection helps enable investigators
and auditors to become more productive, handling broader caseloads
by automating processes previously conducted manually. Increased
productivity can lead to enough accurately identified suspicious claims
to help your organization achieve a rapid return on investment. While
some of the business requirements may differ, our solution can also
address the needs of public payer plans, such as Medicaid, to help
recoup dollars wrongly billed to the system.
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Transform fraud identification with IBM

Collaboration with healthcare payers and our deep involvement with
user groups allow us to offer you a fraud and abuse solution that can
evolve as your business needs change. Our fraud and abuse manage-
ment offering currently used by 30 public and private sector clients to
identify and pursue suspicious claims. IBM brings together industry
and process expertise, systems and business performance software, and
our deep computing and advanced analytics capabilities to tackle your
business challenges.

For more information

To learn more about the fraud and abuse management solution for
payers, please contact your IBM representative or IBM Business
Partner, or visit: ibm.com/healthcare

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