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GCN : July 2015
26 GCN JULY 2015 • GCN.COM ANALYTICS on sharing information to help catch fraudsters. “There is no silver bullet in protect- ing against fraud,” said Mark Nelsen, senior vice president for risk products and business intelligence at Visa. In- stead, payers should field a combina- tion of technology, processes and peo- ple, and use data analytics as a “critical component in making all three of these effective.” The company’s analytics suite evalu- ates as many as 500 data elements to identify suspicious transactions as they occur. The evaluations provide an in- stantaneous rating of a transaction’s fraud potential by checking the history, geolocation and transaction speed of a potentially fraudulent event. THE INVESTIGATION CONTINUUM Vendors say anti-fraud campaigns de- pend on the sharing of pertinent data- sets so that data scientists, program in- tegrity experts and software developers can mount successful fraud cases. “Integration within the data ware- house is absolutely vital because it lets you visualize things you would not see with smaller datasets,” said Elizabeth Snavely, director of fraud, waste and abuse products at General Dynamics IT. Data-visualization techniques also al- low risk managers to monitor a fraud scheme as it unfolds, which Snavely compared to seeing maps of an epi- demic spreading from one side of the country to another. General Dynamics offers a number of applications designed to support the individual stages or the continuum of a fraud case, she said. The first appli- cation generates investigative leads by, for example, flagging the number of patients seen by a clinical provider in a single day. “Let’s say you are looking at a se- ries of providers and they are indicat- ing that they saw 52 patients in a day,” Snavely said. “That’s a red flag. Either that provider is extremely dedicated or the dates in their computer program are wrong.” Could they be telling the truth? “Ab- solutely,” she said, and that’s why lead generation is only the first part of the continuum. Snavely added that although it seems straightforward, “it can take two years to train someone to be a good investiga- tor and pick out those data anomalies.” In the early stages of an investigation, “it’s not necessarily fraud you’re seeing, but it’s finding that string of thread that you’re going to start pulling on.” The next stage of an anti-fraud se- quence involves applying analytics to promising leads. In the scenario in which a doctor claimed to see 52 pa- tients a day, risk managers would look beyond report summaries and ask for all the data on the claims received. At this stage, investigators might seek information on whether all 52 claims had been paid, whether they were all for the same procedure and whether they all had the same diagnoses. “It’s where you start to follow a process and use analytic tools to see what you really have,” Snavely said. In addition to lead generation and analytics, General Dynamics offers a fraud case-management tool that helps maintain program integrity by moving an investigation forward based on the best anticipated financial recovery. One of the last pieces in the com- pany’s product line is a prepayment re- view that provides a final layer of ana- lytics. “You take all that stuff that you learned during your investigation and you feed it into a prepayment system that begins to flag [problems] before the payment is made,” Snavely said. SETTING THE RISK DIAL Given the complexity of a typical fraud case, industry executives say prepay- ment analytics are useful but not per- fect tools. For one thing, most systems flag too many false positives, creating conflict between payers and providers. “I’ve seen these put in place in a few different states,” said Monty Faidley, director of market planning, health and human services at LexisNexis. “The provider community gets upset because too many claims are being stopped or being flagged; they’ve got delays in payments. Those provider networks are often strong lobbying groups, and their complaints get heard very quickly.” “A big component that has been missed in authentication — which the government is really in a game-changing position to demonstrate the value of — is around tying a unique identity to the authorization process.” KEN AMMON, XCEEDIUM 0715gcn_024-028.indd 26 6/30/15 2:30 PM