VISTA Healthplan Selects Fair Isaacs Payment Optimizer to Detect Fraud Before Claims Are Paid

VISTA Healthplan (VISTA) has selected Fair Isaacs Payment Optimizer to enhance the Florida-based healthcare companys fraud detection capabilities. Payment Optimizer will enable VISTA to detect fraudulent and abusive patterns earlier and more accurately in their claims review process, resulting in reduced claims losses and a streamlined payment decision process. Fair Isaacs Payment Optimizer is the only healthcare fraud detection technology available today that can identify patient and provider fraud, abuse and errors before payments are made. As a vital component of VISTAs claim review process, the solution quickly and precisely analyzes each claim received, detects those that warrant review, manages them better to enhance investigative efficiency and improves the bottom line. Successful Pilot Program Fair Isaacs fraud detection software demonstrated its powerful detection capabilities in a 2003 pilot program with the Government Employees Hospital Association (GEHA). GEHA found the majority of claims scored by Payment Optimizer contained payment or billing errors, in addition to outright fraud or abuse. This helped the insurer improve the accuracy of its claims processing procedures by identifying errors that previously went undetected. Further, the solution significantly reduced "false-positive" cases, in which legitimate claims are identified as potentially fraudulent, enabling investigators to focus on the claims with the highest likelihood of fraud, abuse or error. Payment Optimizer also helped GEHA identify several vulnerable points in the overall claims processing procedure, preventing further losses. Payment Optimizer integrates advanced predictive modeling, statistics and rules to detect all types of fraud and abuse. The software identifies patterns of unusual behavior and provides a score based on the claims degree of risk. The score allows claims professionals to determine which claims need to be taken out of the payment stream for further investigation, and allows the rest of the claims to be fast-tracked for payment. The system also provides explanations to help investigators determine the most appropriate action on each high-risk claim. In addition to pre-payment capabilities, Payment Optimizer also offers post-payment functionality to help healthcare entities identify suspicious claims after payment occurs. The solution is deployed for real-time or batch operation and can be easily integrated with clients current claims systems and existing workflow.