A healthcare fraud investigation firm improves criminal research practices

IBM i2 software improves fraud detection and prevention and helps close cases faster

Published on 12-Nov-2013

Customer:
A healthcare fraud investigation firm

Industry:
Healthcare

Deployment country:
United States

Overview

This healthcare fraud investigation firm is headquartered in St. Augustine, Florida, and has offices in all 50 states. The company’s expertise lies in fraud detection and prevention, cyber issues and risk concerns. It provides traditional investigation, predictive plans and data and investigative analysis.

Business need:
A healthcare fraud investigation firm needed to improve its ability to integrate disparate data to detect and prevent healthcare fraud.

Solution:
The firm implemented IBM® i2® sof tware to better combine data sets and highlight links between claims, doctor visits and prescriptions.

Benefits:
A common view of different data formats helps investigators analyze, identify and track various activities, including drug transactions and claims, to determine whether ser vices were rendered.

Case Study

This healthcare fraud investigation firm is headquartered in St. Augustine, Florida, and has offices in all 50 states. The company’s expertise lies in fraud detection and prevention, cyber issues and risk concerns. It provides traditional investigation, predictive plans and data and investigative analysis.

Challenge
With various forms of healthcare fraud being perpetuated daily, this healthcare fraud investigation firm wanted to ensure that the detection and prevention services it provided for customers were as strong as possible. A top priority was to consolidate, streamline and integrate disparate data into one consistent view while leveraging analytical features so billions of rows of data could be processed at a time. The company recognized this would help it pinpoint known healthcare fraudsters and allow for faster case closure. The firm also believed this would improve transaction tracking, helping prevent fraud.

Solution
The healthcare fraud investigation firm implemented IBM i2 Analyst’s Notebook and IBM i2 iBase software to compare patient data against multiple physician practices. The i2 software provides the ability to view overlying transaction data pertaining to claims, which helps the company determine information such as how many claims there are per patient as well as whether there are multiple claims for multiple offices for the same person and whether they correspond. The software also provides granular analysis to identify individuals and companies up-front before fraud is committed.


Identifying known healthcare fraudsters helps the firm close cases faster by tracking prescription drug transactions, vetting fraudulent claims and pinpointing which services were actually rendered.

Further, by recognizing patterns and stopping completion before the billing stage, the firm improves transaction tracking and helps prevent future fraud and customer losses.

Benefits
• Combines and integrates disparate data into one consolidated view
• Allows the firm to process billions of rows of data at a time, which helps close cases faster
• Improves fraud detection and prevention capabilities with granular analysis

For more information
To learn more about IBM i2 software, please contact your IBM marketing representative or IBM Business Partner, or visit the following website: ibm.com/software/industry/i2software.

Products and services used

IBM products and services that were used in this case study.

Software:
i2 iBase, i2 Analyst's Notebook

Legal Information

© Copyright IBM Corporation 2013 IBM Corporation Software Group Route 100 Somers, NY 10589 Produced in the United States of America November 2013 IBM, the IBM logo, ibm.com and i2 are trademarks of International Business Machines Corp., registered in many jurisdictions worldwide. Other product and service names might be trademarks of IBM or other companies. A current list of IBM trademarks is available on the Web at “Copyright and trademark information” at www.ibm.com/legal/copytrade.shtml. This document is current as of the initial date of publication and may be changed by IBM at any time. Not all offerings are available in every country in which IBM operates. The performance data and client examples cited are presented for illustrative purposes only. Actual performance results may vary depending on specific configurations and operating conditions. THE INFORMATION IN THIS DOCUMENT IS PROVIDED “AS IS” WITHOUT ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING WITHOUT ANY WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND ANY WARRANTY OR CONDITION OF NON-INFRINGEMENT. IBM products are warranted according to the terms and conditions of the agreements under which they are provided.