Healthcare

Healthcare

Know Your Claim is the most innovative and comprehensive Predictive Modeling solution in the industry. It comprises of a suite of advanced pre-payment and post-payment analytical platforms to perform behavioral analysis, artificial intelligence and social analysis on cross-claims data.
Predictive analytics for detecting fraud in provider claims

Know Your Claim is the most innovative and comprehensive Predictive Modeling solution in the industry. It comprise of a suite of advanced pre-payment and post-payment analytical platforms to perform behavioral analysis, artificial intelligence and social analysis on cross-claims data.

Unlike rule-based editing, the solution evaluates each claim in the context of of all related and similar claims using forensic-style hyper-dimensional analysis to detect claims associated with fraud and abuse. In contrast to the utilization based provider outlier analysis, the approach focuses on the improbabilities associated with individual encounters represented by the claims.

Some of its

Predictive Analytics

Best-of-breed behavioral, network and predictive analytics algorithms

Intelligent Correlation

Correlation with commercial provider demographic and profile data

Electronic Investigation

High-speed digital investigation based on 360 degree views and associated spatial, temporal and link analysis

Configurable Workflow

Integrated digital workflow to triage and decision on alerts including medical records review

Capabilities

  • PREDICTIVE ANALYTICS Best-of-breed behavioral, network and predictive analytics algorithms
  • INTELLIGENT CORRELATION Correlation with commercial provider demographic and profile data
  • ALERTS ON CLAIMS Near-time alerts on high-risk claims, providers, beneficiaries and vulnerabilities
  • ELECTRONIC INVESTIGATION High-speed digital investigation based on 360 degree views and associated spatial, temporal and link analysis
  • CONFIGURABLE WORKFLOW Integrated digital workflow to triage and decision on alerts including medical records review
  • COMMAND & CONTROL DASHBOARDS monitor, measure, and respond to ongoing risks and vulnerabilities
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