Solutions for Fraud & Abuse Detection

Data-Driven Anomaly Identification

Annual health care expenditures in the U.S. have exceeded $1.3 trillion according to the Health Care Financing Administration. Simultaneously, the loss by insurance companies and government agencies due to fraudulent healthcare transactions are estimated at $100 billion, amounting to 10% of the nation's annual health care expenditure. Timely detection and prevention of fraud and abuse can help recover enormous amounts of money and return it back to medical institutions and patients, improving the quality and decreasing the cost of healthcare for millions of taxpayers.

Megaputer's fraud and abuse detection tool MediCop™ is a module of the analytical platform PolyAnalyst. The tool helps detect and investigate fraud and abuse suspects through the analysis of healthcare insurance claims. Going beyond the capabilities of standard rule-based systems, PolyAnalyst employs advanced data-driven techniques for detecting typical treatment patterns based on the analysis of large volumes of claims and then discovering pronounced deviations from such patterns. In this manner, the system isolates anomalous providers and discovers fraud instances that do not follow the known schemes. PolyAnalyst provides interactive visualization and multi-dimensional reporting tools to support further in-depth investigation of potential fraud suspects.

Making a single assumption that the vast majority of providers and patients have legitimate behavior, the MediCop system learns typical treatment patterns and then detects significant deviations from these patterns.

Our software enables you to:

• Readily integrate data from disparate data sources
• Automatically detect typical treatment patterns and deviations from them
• Perform pre-payment and retrospective automated fraud detection
• Easily carry out elaborate investigations scenarios uncovering precise fraud scenarios
• Detect previously unknown fraud scenarios missed by rule-based systems
• Build multi-step data analysis scenarios through a drag-and-drop interface
• Schedule processing to run at a pre-determined time
• Generate customized reports summarizing key findings
• Process huge volumes of claims