Fraud Detection System

Intelligent Investigator™ powered by SPOT™ our rules-based inference engine, and PATE™ our predictive analytic technology engine, is an advanced fraud detection system built exclusively for healthcare payor investigative teams.

Intelligent Investigator is a highly engineered fraud detection system that pinpoints patterns of suspicious behavior across all healthcare claim types, including, medical, facility, pharmaceutical and dental. With its easy-to-use Graphical User Interface (GUI) Intelligent Investigator effortlessly walks users of all levels through potentially fraudulent cases in order to uncover actionable findings. The advanced drill-down feature allows users to trace leads by provider, member/patient, transaction and other related data with ease. Special screens are designed to assist investigators in identifying providers or claims, based on partial information or tips from fraud hotlines. The user-friendly system also supports usage by non-investigative departments such as provider relations, medical economics, finance and internal audit.

The Composite Lead Indicator (CLI) built into Intelligent Investigator makes it easy to identify the most lucrative leads. The CLI is a proprietary indexing tool that prioritizes the potential savings and recovery probability of each lead in order to establish the recommended order of case sequencing. By using CLI investigators know which claims are the most worthwhile to investigate, thereby saving time and rendering the greatest results.

Our innovative ad-hoc reporting system enables users to create customized reports instantly without having to rely on internal IT support. The system offers hundreds of preformatted reports that run seamlessly in the system background, allowing for uninterrupted usage. Reports can be generated to reflect singular or multiple provider results. Additionally reports can be generated across several lines of business for a “big picture” review of FWA activity.

Intelligent Investigator integrates fully with Trail Tracker™ our fraud, waste and abuse case tracking management and recovery system.Trail Tracker greatly reduces the time and effort necessary to build solid cases for full-scale investigations. Both are written in modern java and will instantly run on any networked PC, or are available as a SaaS (Software as a Service) fully hosted option.

Benefits include:

• Quickly guides investigators to the most valuable recoveries
• Quickly pinpoints suspect behavior identified by SPOT™
• Allows investigative view of outliers and trends
• Speeds investigators’ understanding of a provider’s billing practice
• Promotes a holistic view of patient, claim and pharmacy data
• Quickly analyzes large lists of suspect providers and/or claims
• Facilitates the compilation of data necessary to prepare a case
• Allows non-IT experts to mine data for new types of fraud
• Enables non-IT experts to target specific providers and claims based on incomplete data