SAS’ Healthcare Fraud Solution Helps Reduce Healthcare Spending by Millions

Predictive analytics detect fraud schemes accurately

CARY, NC – Healthcare fraud costs society $60-$100 billion a year and the expense is passed along to patients in the form of higher healthcare costs. Everyone wants to see healthcare costs reduced and fraud detection from SAS, the leader in business analytics, can help achieve this. SAS® for Healthcare Fraud Detection and Prevention applies predictive analytics to help insurers reduce healthcare spending by millions.

Using historically-available techniques, only 10 percent of losses to fraud, waste and abuse are ever detected. Furthermore, because of current post-payment “pay-and-chase” approaches, only 1 percent of losses are recovered.

Analytics actually identifies fraud schemes, so health insurers can prevent payment on false claims. Beginning with extensive data integration, SAS for Healthcare Fraud Detection and Prevention pulls all data needed to uncover and investigate fraudulent activity. Integrating known fraud detection business rules, the solution flags information about claims, providers and enrollees for any past fraudulent activity. SAS’ world-class predictive modeling techniques are employed to detect emerging fraud schemes, prioritize elements to be investigated, and manage the investigation workflow. Results go back into the SAS solution to continually improve the detection process while other products rely solely on rules that are only updated as vendors provide new releases.

Rick Pro, principal healthcare strategist at SAS commented, “The predictive analytical element of fraud and abuse detection is essential for commercial and government payers. It’s the most effective way to reduce inappropriate spending in healthcare, saving those dollars for warranted health benefits”.

Highmark – the Pennsylvania-based Blue Cross Blue Shield affiliate that covers more than 25 million Americans – is hot on the trail of fraudsters, including the insured, providers, pharmacies and third-party billers. Highmark uses predictive analytics to build sophisticated models from huge stores of claims, customer and provider data. Those models provide easy, automated access to intelligence that uncovers and prevents costly crimes – to the tune of $11.5 million.
A Suite of Integrated Healthcare Solutions

Under increased pressure to improve business practices, health insurers are using SAS to shift from reactive to proactive by predicting – and responding to – challenges before they occur.

SAS’ comprehensive solutions for health insurance offer everything necessary to make solid business decisions, align actions with business strategy, improve operational efficiency and increase bottom-line results. SAS solutions address customer intelligence, operational intelligence, health plan reporting, health plan intelligence, health insurance fraud, health informatics intelligence and disease management.

About SAS
SAS is the leader in business analytics software and services, and the largest independent vendor in the business intelligence market. With innovative business applications supported by an enterprise intelligence platform, SAS helps customers at 45,000 sites improve performance and deliver value by making better decisions faster. Since 1976 SAS has been giving customers around the world The Power to Know® .