Health Insurance Claims Fraud Detection Systems: 2015 IT Vendor Spectrum
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)
- Hugin Expert A/S
- iGATE Corporation
- INFORM GmbH
- LexisNexis Risk Solutions
- Lorica Health
- 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 subsidiary of Marsh & McLennan Companies [NYSE: MMC].
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Table of Contents
Key Research Questions
An Overview of the IT Vendor Spectrum
BAE Systems Applied Intelligence: NetReveal for Healthcare
Fair Isaac Corporation (FICO): FICO Insurance Fraud Manager – Healthcare and the FICO Payment Integrity Platform
FRISS Fraud Risk and Compliance: FRISS Platform
Hugin Expert A/S: HUGIN FDM
IBM: SOLON Business Solution as a Service (BSaaS)
iGATE Corporation: xClaim
Inform GmbH: Risk Shield
LexisNexis Risk Solutions: LexisNexis Intelligent Investigator; LexisNexis PrePayment Manager; LexisNexis Trail Tracker
Lorica Health: Hibis; I-Plus
Optilab: Admiral Health
Performant: Performant Insight Data System
SAS: SAS Fraud Framework for Health Care
Verisk Health: Core Editing, Clinical Validation, FWA Detection, Pharmacy FWA Detection, High-Cost Claim Review, Case Tracker
Leveraging Celent’s Expertise
Support for Financial Institutions
Support for Vendors
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