Rules-Based Inference Engine

SPOT™ (Systematic Profiling on Time) serves as the intelligence platform for our fully integrated suite of post-payment anti-fraud, waste and abuse products built exclusively for healthcare payors.

As an expansive knowledgebase, SPOT contains historical information on thousands of providers and millions of claims that were culled from both internal and client investigative teams. In addition, SPOT contains intelligence from outside sources such as the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), industry experts and training conferences. SPOT covers all healthcare claim types, to include, medical, facility, pharmaceutical and dental, eliminating the need for healthcare payors to manage multiple software modules. Consequently, SPOT is not limited to simply targeting 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.

SPOT’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. 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 SPOT implementation is quick and easy since there is no need to build time-consuming and costly statistical models. This means investigators can begin targeting suspected claims immediately with Intelligent Investigator™ our post-payment fraud detection system and Trail Tracker™ our fraud, waste and abuse case tracking management and recovery system.