Pre-Payment Rules-Based Inference Engine

PreSPOT™ (Pre-Payment Systematic Profiling on Time) serves as the intelligence engine for Payment Protector™ our pre-payment fraud prevention system built exclusively for healthcare payors.

PreSPOT shares the same expansive knowledgebase as SPOT™, our post-payment rules-based inference engine. As such, PreSPOT contains historical information on thousands of providers and millions of claims culled from both internal and external investigative teams. In addition, PreSPOT contains intelligence data vetted from outside sources such as the American Medical Association (AMA), The Centers for Medicare and Medicaid Services (CMS), industry experts and training conferences. PreSPOT encompasses all healthcare claim types to include, medical, facility, pharmaceutical and dental. Consequently, PreSPOT is not restricted to simply identifying outliers and trends, but is able to analyze each and every claim against a comprehensive intelligence base that includes thousands of rules, algorithms and measures.

PreSPOT’s flexible rules-based structure makes it easy to add or modify rules when investigators detect new schemes. These new rules seamlessly update existing provider profiles and related behavioral patterns to identify and target new opportunities. Just like SPOT, these profiles and patterns are built and tracked over a multitude of factors including patient visits, procedure codes and modifier usage, so that companies can easily meet state-mandated regulations.

With PreSPOT implementation is quick and easy since there is no need to build time-consuming and costly statistical models, meaning investigators can begin targeting questionable claims immediately with Payment Protector our pre-payment fraud prevention system.