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  Healthcare Product Suite

  Know Your Claim – (KYC)

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.

>Know Your Claim (KYC) comprises of six modules and Medicaid-specific fraud detection models to deliver comprehensive monitoring and analysis of claims against cross-claims data

 

Predictive Analytics: Best-of-breed behavioural, 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 and Control Dashboards: monitor, measure, and respond to ongoing risks and vulnerabilities

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  Key Capabilities

Predictive Analytics

Predictive Analytics


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

Intelligent Correlation

Intelligent Correlation


Correlation with commercial provider demographic and profile data

Alerts on Claims

Alerts on Claims


Near-time alerts on high-risk claims, providers, beneficiaries and vulnerabilities

Electronic Investigation

Electronic Investigation


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

Configurable Workflow

Configurable Workflow


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

Command and Control Dashboards

Command and Control Dashboards


monitor, measure, and respond to ongoing risks and vulnerabilities

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