New York, N.Y.-based Verizon is making available to government and private health insurers throughout the U.S. an automated fraud-detection platform that is meant to help these organizations better detect and prevent fraud, which Verizon says results in more than $250 billion a year in losses.
The offering, Verizon Fraud Management for Healthcare, is a software platform tailored to the health care industry that uses predictive modeling technology to examine health care payment requests and route potentially fraudulent claims to case managers for investigation. The highly scalable platform is designed to help identify fraud before payments are made, reducing improper payments, and the administrative and legal costs associated with traditional "pay-and-chase" recovery operations.
According to the U.S. Department of Health and Human Services, in 2009, the most recent year for which statistics are available, national health expenditures totaled $2.5 trillion, representing 17.6 percent of U.S. gross domestic product. It is estimated that fraud accounts for as much as $260 billion, or at least 10 percent of the annual U.S. health care expense.
Predictive modeling is commonly used in the financial services and telecommunications industries to combat fraud. It employs advanced algorithms and analytics, including link, behavioral and statistical analysis, to monitor huge volumes of information in near real time to help identify cases of potential fraud prior to processing and payment.
The Verizon fraud-detection solution employs a customized version of the software platform the company uses for its own fraud prevention programs. The internal platform processes more than 20 billion records on a day, including more than 700 million call records.