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Utilizing Analytics to Help Fraud Detection for Healthcare Organizations

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Healthcare expenditures in the U.S. are projected to reach $3.2 trillion in 2015. Another report also pointed out financial losses from healthcare fraud amount to tens of billions of dollars annually.

Given these numbers, healthcare administers are looking for more efficient ways to reduce risk exposure and related financial losses. Improper payments are currently the single largest cause of revenue loss for healthcare payers, if we translate this sentence into number – on average, individual healthcare payers are losing 10 percent of their annual revenues due to these improper payments.

Methods of improper payments in organizations are becoming more diversified and complex with an annual increasing rate of 50%. Among all the health care frauds, claim leakage and loss adjustment expenses are rising faster. The growing sophistication of improper payment activity is troublesome for special investigative units (SIUs) who aim to resolve cases quickly and direct their skilled resources to high-risk cases.

For healthcare payers already struggling to maintain their reputation and dealing with significant, growing financial losses, these statistics are motivating. While senior management and the board are ultimately responsible for a fraud management program, internal audit can be a key player in helping address fraud. By providing an evaluation on the potential for the occurrence of fraud, internal audit can show an organization how it is prepared for and is managing these fraud risks. Organizations need deep intelligence to confidently prevent, detect and stop fraud.

With years of consulting experience, Cresco International, a partner of IBM, aims to address these challenges with the  latest technology – IBM Counter Fraud and Improper Payments Management. This solution enables healthcare organizations to prevent and intercept new cases of improper payments while detecting, identifying, and building the case against past improper payments activity. It digs into the entire lifecycle of improper payments operations using tightly woven capabilities including big data and entity analytics to integrate information silos, combine observation spaces, and enable unified enterprise business intelligence.


IBM Counter Fraud Management


Multiple functions, such as robust dashboards, and system reports, are built in this solution to eliminate frauds. Now, you not only can proactively calculate the impact of changes to operations and productivity, but also can visualize contextual correlations to gain deeper insight.

For more information on how your healthcare organization can prevent detect fraud, contact us today.

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