Healthcare Fraud Prevention
Find unique patterns in your data by utilizing identity matching, behavior profiling and predictive models.
Fraud prevention is a core capability of the Infogix Enterprise Data Analysis platform that provides multiple layers of protection against fraud. Our fraud management solution utilizes identity matching and behavior profiling and predictive models to find unique patterns in your data, such as aliasing capabilities to determine people trying to use different identities and usage profiling where self-learning algorithms continuously monitor for fraudsters trying to game the system.
Eliminate Fraud from the Point of Entry
The Infogix fraud data analysis allows you to guard against identity thieves, repeat offenders and high risk subscribers, starting at the point of entry into your enterprise. With sophisticated analytics engines that use matching and scoring algorithms, Infogix’s aliasing and customer risk scoring engines validate all relevant applicant information against a database of known offenders.
Behavior Profiling Enables Early Detection
Early in the lifecycle of a new provider, member, or broker is the time when a company’s vulnerability is highest. With intelligent threshold adjustments and pattern identification (a.k.a. fingerprinting) behavior analysis, Infogix tightly monitors usage, transactions, changes to contact information and variations in expected behavior. This enables the fraud management team to stop abuse at the first indication of suspicious behavior from new constituents. Infogix’s Fingerprinting Engine continually evaluates usage and behavior of new providers or members. When a new constituent’s usage pattern matches the pattern of a previous fraudulent constituent an alert is generated. Payers have the capability of configuring the degree of match with the fraudulent pattern. This powerful Engine enables fraud managers to detect fraudulent subscribers very early in the customer lifecycle within a period when traditional fraud detection systems would not identify them.
Powerful Aliasing Engine Stops Identity Thieves and Returning Fraudsters
The Infogix Aliasing Engine allows Special Investigative Unit (SIU) managers to determine whether the new provider or member is an identity thief or returning fraudster and, most importantly, to prescribe specific actions for both. The provider previously terminated due to fraudulent activity may return with a slightly altered name. Sophisticated aliasing logic will detect this similarity and immediately alert your staff. Providers will also reenter the system using a straw for their corporation or service entity and we can check to see if a new “control person” (e.g., partner, director, officer) is closely related to the old excluded provider.
Customer Risk Scoring: You’re in Control
Once a new provider or member has come on board it is important to monitor their behavior during the initial days of their participation. Infogix keeps track of risk scores for each constituent. This capability allows companies to set tighter usage and transaction limits for these newly acquired and high risk constituents.
Identify Fraudsters throughout the Customer Lifecycle with Usage Profiling
Infogix’s Usage Profiler enables fraud managers to identify fraudulent providers and members throughout their lifecycle. Our powerful Profiling Engine accumulates usage and transaction statistics across various service dimensions and time intervals. It monitors statistics for each individual profile and identifies appropriate thresholds based on their current usage patterns. This enables the profiler to “self learn” the usage pattern for each individual entity for each of the applicable transactions, by different usage dimensions and at different time intervals, in order to take appropriate actions based on the profile/risk of the constituent.
Infogix Reporting: The Right Information, at the Right Time.
- Investigators can guide their attention to the highest risk exposure, presenting all the information needed to quickly investigate and stop the abuse, and providing all the analysis needed to fine tune detection.
- Managers get all the information needed to monitor the load and performance of investigators, manage the department, report tangible results to executives and assess the overall effectiveness of the analytics engines.
- Executives receive Key Performance Indicators (KPIs) needed to analyze trends, overall department performance, impact on company financial health, risk exposure and return on the investment.
A Comprehensive Approach to Risk and Fraud Management
Our capabilities offer a unique and revolutionary approach that moves away from traditional profiling tools that only monitor usage. Infogix’s rule builder and behavioral analysis engines are continuously learning, monitoring and self-adapting in order to more accurately detect fraud at the very first instance of unusual behavior. Additionally, depending on the customer’s setup, we profile “entities” which could be any of multiple constituents. We leverage our understanding of the customer’s business in order to profile these “entities”. This approach allows us to effectively partner with customers to manage risk and fraud for the long term, across the convergent spectrum of technologies, services and fraud types.