The healthcare fraud and abuse management solution for payers from IBM supports a diverse range of fraud investigation and management both before and after claims payment, including prevention, investigation, detection and settlement.

1. IBM Sales and Distribution Healthcare payers
Solution Brief
Fraud and abuse
management for payers
Prevent and detect fraudulent claims
To uncover fraudulent and abusive behavior, investigators must sort
Highlights through millions of individual claims to find suspicious behavior, often
relying on a pay-and-chase strategy—pursuing cases after claims have
● Support a diverse range of fraud already been paid. IBM has worked closely with healthcare investiga-
investigation before and after claims
payment tors to develop the fraud and abuse management solution for payers
with both proactive and retrospective detection capabilities.
● Sort millions of claims in minutes and
rank providers by degree of potentially
abusive behavior A sophisticated, comprehensive solution
Detecting suspicious claims activity—such as billing for services not
● Pinpoint claims most likely to be fraud-
ulent or erroneous with advanced algo- performed, billing more expensive claims than the actual service ren-
rithms and analytical models dered, overprescribing tests and medications, and requiring tests and
● Achieve rapid return on investment by
procedures that are not medically necessary—is a difficult data-
enabling investigators and auditors to intensive task. The fraud and abuse management solution for payers
become more productive 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

2. 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
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Without the tools to systematically and scientifically uncover suspi-
Produced in the United States of America
cious claims, investigators must rely on tips from fraud hotlines, or use May 2010
spreadsheets and database queries to perform relatively simple analysis. All Rights Reserved
The fraud and abuse management solution can allow them to sort mil-
IBM, the IBM logo and ibm.com are trademarks or
lions of claims in minutes, and then rank providers by degree of poten- registered trademarks of International Business Machines
tially abusive behavior. This can help speed and extend the ability to Corporation in the United States, other countries, or both. If
these and other IBM trademarked terms are marked on their
recover mistakenly paid claims and reduce wrongful medical payments.
first occurrence in this information with a trademark symbol
(® or ™), these symbols indicate U.S. registered or common
Our approach to fraud and abuse detection helps enable investigators law trademarks owned by IBM at the time this information
was published. Such trademarks may also be registered or
and auditors to become more productive, handling broader caseloads
common law trademarks in other countries. A current list of
by automating processes previously conducted manually. Increased IBM trademarks is available on the Web at “Copyright and
productivity can lead to enough accurately identified suspicious claims trademark information” at ibm.com/legal/copytrade.shtml
to help your organization achieve a rapid return on investment. While Other company, product or service names may be trademarks
some of the business requirements may differ, our solution can also or service marks of others.
address the needs of public payer plans, such as Medicaid, to help
recoup dollars wrongly billed to the system. Please Recycle
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
HHS03005-USEN-00