Health Insurance Claims Fraud Detection Systems: 2015 IT Vendor Spectrum

by Mohammed Mahfuz,  Nicolas Michellod, March 9, 2015
Vendor Reviews
Global

Abstract

Mitigating claims fraud is a critical process for insurers if they want to generate profitable business, and health insurance is an area where claims fraud detection requires particular attention.  

In the report Health Insurance Claims Fraud Detection Systems: 2015 IT Vendor Spectrum, Celent reviews IT vendors and their offerings in the claims fraud detection area with specific focus on health and medical insurance.

“Medical insurance claims handling is a complex process where multiple parties are involved including various medical providers,” says Nicolas Michellod, a senior analyst with the Celent’s Insurance practice and coauthor of the report.

“Specific functions and features are required if health insurers want to do a good job at mitigating claims fraud,” adds Mohammed Mahfuz, an analyst with the Celent Insurance practice and coauthor of the report.

This report provides a detailed description of IT vendors and their offerings in medical claims fraud detection. It profiles 13 IT vendors and is not restricted to a specific geography. Each vendor is profiled using the same structure, starting with a synoptic table presenting the company and its solution. Celent describes the system’s functionality, the customer base, technology as well as implementation, pricing and support.

The vendors profiled in this report are:

  • BAE Systems Applied Intelligence
  • Fair Isaac Corporation (FICO)
  • FRISS
  • Hugin Expert A/S
  • IBM
  • iGATE Corporation
  • INFORM GmbH
  • LexisNexis Risk Solutions
  • Lorica Health
  • Optilab
  • Performant
  • SAS
  • Verisk Health

Although this list is not exhaustive, we think it provides a valuable sample of vendors, which already have experience of implementations in the health insurance industry.

Celent is a research and advisory firm dedicated to helping financial institutions formulate comprehensive business and technology strategies. Celent publishes reports identifying trends and best practices in financial services technology and conducts consulting engagements for financial institutions looking to use technology to enhance existing business processes or launch new business strategies. With a team of internationally based analysts, Celent is uniquely positioned to offer strategic advice and market insights on a global basis. Celent is a member of the Oliver Wyman Group, which is a wholly-owned operating unit of Marsh & McLennan Companies [NYSE: MMC].

Media Contacts

North America
Michele Pace
mpace@celent.com
Tel: +1 212 345 1366

Europe (London)
Chris Williams
cwilliams@celent.com
Tel: +44 (0)782 448 3336

Asia (Tokyo)
Yumi Nagaoka
ynagaoka@celent.com
Tel.: +81 3 3500 3023

Table of Contents

Executive Summary

1

 

Key Research Questions

1

An Overview of the IT Vendor Spectrum

2

BAE Systems Applied Intelligence: NetReveal for Healthcare

6

Fair Isaac Corporation (FICO): FICO Insurance Fraud Manager – Healthcare and the FICO Payment Integrity Platform

11

FRISS Fraud Risk and Compliance: FRISS Platform

16

Hugin Expert A/S: HUGIN FDM

21

IBM: SOLON Business Solution as a Service (BSaaS)

26

iGATE Corporation: xClaim

31

Inform GmbH: Risk Shield

36

LexisNexis Risk Solutions: LexisNexis Intelligent Investigator; LexisNexis PrePayment Manager; LexisNexis Trail Tracker

41

Lorica Health: Hibis; I-Plus

45

Optilab: Admiral Health

50

Performant: Performant Insight Data System

55

SAS: SAS Fraud Framework for Health Care

60

Verisk Health: Core Editing, Clinical Validation, FWA Detection, Pharmacy FWA Detection, High-Cost Claim Review, Case Tracker

65

Leveraging Celent’s Expertise

70

 

Support for Financial Institutions

70

 

Support for Vendors

70

Related Celent Research

71

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