Uncovering More Fraudulent Health Care Providers with FICO® Identity Resolution Engine

Summary Many insurance payers realize how valuable Identity Resolution and Link Analysis technology can be in supporting detection of organized crime, as well as opportunistic fraudulent providers. But they also know how difficult it is to implement on proprietary platforms. Now, with FICO® Identity Resolution Engine as a component of FICO® Insurance Fraud Manager, health care insurers can immediately access the industry’s most innovative entity data matching technology to reduce losses with a more holistic view into criminal activity and networks.

In a recent report to the Senate Finance Committee, the National Health Care Anti-Fraud Association applauded The Centers for Medicare and Medicaid Services’ recognition of the value of pre-payment anti-fraud technology, including the application of predictive analytics. Stating that the “pay and chase” model of combating health care fraud is no longer tenable as the primary method of fighting fraud, the report went on to advise that private-sector health plans should be incentivized to invest in and deploy anti-fraud technology, including pre-payment applications. FICO is adding to the validity of that position, and to the efficacy of pre-payment analytics, with FICO Identity Resolution Engine. Its advanced technology complements claims and provider scoring in FICO Insurance Fraud Manager, adding another dimension of discovery. Insurance Fraud Manager can analyze up to one billion claim lines for fraud risk, as well as providers’ billing or care patterns, looking for behavior aberrant to the peer group. FICO Identity Resolution Engine takes the analysis to the next dimension, finding networks of relationships among organizations, individuals and transactions. Applicable in reactive investigations to incoming claims, or in proactive mode, payers can use the solution’s identity resolution and linking technology to search across a variety of attributes—such as locations, service providers, telephone numbers, names and identifiers (License, NPI, DEA Numbers)—to uncover hidden relationships behind criminal fraud rings. Payers can determine whether a provider’s or patient’s personal or claims data appears to be suspicious, and whether that person is linked with other providers or members who may also be suspected of involvement in a fraud ring or fraud activity.

In addition to uncovering rings, the solution can help payers find more opportunistic fraud by providing another dimension of analysis on providers following FICO’s provider scoring. Conversely, it can improve payer/provider relations by reducing false positives.

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Uncovering More Fraudulent Health Care Providers with FICO® Identity Resolution Engine

Immediate Use with FICO Pre-Configured Data

A Major Difference Over Other Link Analysis Solutions

SIU Data Provider Data Third Party Data Provider Data

1065A Sixth AveClinton MA, 01510Tel# 978-555-0123

Member ID# 1234-567-88

3245 South BluffClinton MA, 01510Previous Address:

1065 Sixth Ave,Clinton MA

Tel# 213-555-0179

Mr. Reid Hopine Ms. Cathryn Lawley

Patient/Member Data Patient Data

Dr. Bob Jones Dr. Robert JonesDr. John Smith Dr. Jon Smythe

Get Better HospitalSuite 301A

LIC# A113203Tel# 978-555-0123

Member# (on claim):1234-567-88

Get Better ClinicSuite 301

LIC# A113303Tel# 978-555-0223

Get-Better HospitalSuite 301

LIC# G66287Tel# 213-555-0179

Get Better ClinicSuite 301A

LIC# G66288Tel# 978-555-0223

Relationship

IndividualIndividual

Relationship

Relationship Relationship

PotentialFraud Ring

FIGURE 1: IDENTIFYING FRAUDULENT PROVIDERS, MEMBERS AND RINGS

©2014 Fair Isaac Corporation. All rights reserved. page 2

For many payers, the primary impediment to deploying link analysis is the high degree of difficulty in implementing an effective link analysis system. Database development and management requires a significant IT, financial, time and resource investment; and proper weighting of attributes is complex.

Because FICO® Identity Resolution Engine is seamlessly integrated into FICO Insurance Fraud Manager, it minimizes deployment and configuration issues. It provides payers with click-access to a choice of pre-configured data sets and screens to search for relationships based on shared addresses, shared members and member-family connections. Payers can rely on their existing Insurance Fraud Manager databases, the same data sets used to score claims and providers.

The power and accuracy of FICO Identity Resolution Engine is unparalleled in the health care insurance industry, and across all other industries—a fact substantiated by the US government.

That government-grade validation is the result of an advanced, seamless approach to searching across disparate data sources, and the power of FICO’s analytic technology. FICO® Identity Resolution Engine differentiates itself from other data matching systems with:

• A cross-database approach that makes it possible for a payer to access virtually any data sources that it provides to FICO for use in FICO Insurance Fraud Manager, eliminating the need to build a data warehouse and move data into a separate repository.

• A library of more than 50 algorithms to automate the matching and relationship identity process with extremely high precision and speed.


This graphic shows how FICO® Identity

Resolution Engine performs cross data-

base Identity Resolution and link analysis.

For example, if a Dr. John Smith filed a

claim for services on a Mr. Reid Hopine,

FICO’s link analysis can first determine

whether a payer should be suspicious

of the provider submitting the claim

by analyzing their personal data across

databases. If the provider appears to be a

likely fraud perpetrator, link analysis can

expand the search to possibly uncover a

ring. The discovery of relationships can

also be expanded to patients; in this case,

Mr. Hopine is linked to Dr. Smith, suggest-

ing collusion. Furthermore, payments on

claims from Dr. Smith for services ren-

dered to Ms. Lawley can be investigated

after link analysis demonstrates a shared

address between Ms. Lawley and

Mr. Hopine, suggesting a family relation-

ship and the possibility of additional

fraudulent activity.



Intelligent Data Access

How It Works: Three Core Functions

FICO Identity Resolution Engine gives a payer’s investigators the fastest and most comprehensive technology to determine who’s who and who knows whom across data sources. Unlike other methods, there’s no need to develop a separate data warehouse, move data into a common repository and cleanse and normalize the data. It’s easy to leverage the value of any data sources, without the exorbitant costs, time delays and resource drain required by other methods.

FICO Identity Resolution Engine gives investigators access to multiple data sources—at once. Rather than logging on and off of each data source in succession—for example, individually searching separate data sources on members, employees, claims, negative data watch lists or other data sources provided to FICO—FICO’s link analysis capability accesses all data sources simultaneously. This enables investigators to triage cases in minutes or seconds, rather than days or weeks.

FICO Identity Resolution Engine also surpasses other network analysis solutions by retaining the forensic value of data, thereby supporting the strength of future analysis. Many data matching systems discard valuable forensic data as part of the data cleansing process. For example, if a payer determines that a John Doe is an alias and the correct name is Jon Doe, many systems will automatically discard all John Doe references after the determination is made, thereby diminishing the forensic value of data searches. However, FICO link analysis retains all of the correct information—so there’s no rework when the case gets turned over to litigation.

FICO® Identity Resolution Engine in FICO® Insurance Fraud Manager provides three core functions for health care insurers: Cross Database Identity Resolution, Link Analysis and Real Time Visualization. In each function the system looks for matches across three pre-configured searches: Shared Addresses, Shared Patients and Member-Family Connections. In just minutes or seconds, the technology helps investigators:

• Determine that an individual is using multiple, various versions of personal attribute information—an indication of a fraud perpetrator.

• Uncover links between disparate individuals sharing the same personal attribute information—an indication of a possible fraud ring.

• Visually analyze matches and relationships on-screen in FICO Insurance Fraud Manager.

Cross Database Identity Resolution gives payers a method to develop identity similarities with the system’s federated, single search functionality. The identity resolution functionality intelligently searches across disparate databases for variations in spelling, addresses and formats, and determines matches using more than 50 algorithms.

When an investigation is launched, the technology’s identity resolution analytics will compare attributes of the patient and provider across the payer’s data sources, such as medical claims, dental claims, pharmacy claims, facility claims, provider records, patient data, employer data and internal Special Investigation Unit (SIU) cases. The technology analyzes personal attributes—such as name, street address, city/state/zip, social security number, federal tax IDs, date of birth or telephone contact—across databases to identify likely identity matches. Unlike other entity matching technology, the FICO system also scores the match in terms of its likelihood of representing the same person.

Link Analysis produces linkages between suspicious members and providers and other individuals. Once a member or provider has been deemed suspicious, investigators can then find connections between that suspicious person and other members or providers, as well as other individuals such as family relatives of members. The technology enables investigators to uncover non-obvious relationships by exploring attributes across databases. For example,

For Reactive Investigations and Proactive Fraud Detection


attributes, such as a phone number from the suspicious provider, may be found to match attributes of a patient in the insurer’s database, suggesting collusion. Investigators can then determine if that patient’s attributes match attributes of other patients or providers, suggesting a ring.

Link analysis technology also opens the door to the potential inclusion of employee data, OIG exclusion lists and other data, if the insurer has access to those networks and data feeds.

Real Time Visualization gives investigators an on-screen graphic display of the matches that it has determined as suspicious. Its icons identify the degrees of separation between the member or provider, similar member or provider identities found in various databases and other individuals that the member or provider is connected to by way of shared attributes.

Insurers can apply FICO® Identity Resolution Engine in reactive investigations as a regular part of their claims review process, or in a proactive approach to identifying networks. In reactive investigations, the technology is applied when a FICO® Claims Fraud Score identifies an incoming claim or associated provider as suspicious of fraud. As shown in Figure 3, the suspicious provider is now a suspect. To determine if the provider should be suspected of criminal involvement, investigators use FICO Identity Resolution Engine to perform targeted searches across various internal or external databases looking for shared personal attribute information with other suspects or known criminals.


Investigator Request

Matches

Link Analysis

Case Manager

Patient Provider ThirdParty Employer Medical

ClaimsDentalClaims

PharmacyClaims

FacilityClaims

DataSources

With FICO® Identity Resolution Engine, a payer’s investigators can access an unlimited number of data sources simultaneously, significantly expediting their triage of cases. Rather than having to import data from sources into a separate repository (and cleanse and format data), the federated search technology allows investigators to look at data as it appears in its original location and source format. Investigators can perform a single search into multiple data sets, eliminating the need to successively log on and off separate databases.

FIGURE 2: SINGLE SEARCH ACCESS TO MULTIPLE DATABASES

Known Suspect Targeted Search Specific OutputR

EAC

TIV

EIN

VES

TIG

ATIO

N

Broad Search AnalyticallyPrioitized Results

New Suspects

PR

OA

CTI

VE

FRA

UD

DET

ECTI

ON

FIGURE 3: PROVIDING DEEPER DETECTION WITH REACTIVE AND PROACTIVE INVESTIGATIONS

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A Critical Component of an Integrated Solution

Figure 3 also shows how the technology can be used in proactive investigations, searching for suspect providers that could trigger alerts to future incoming claims. Investigators can perform broad-based searches of various individuals to find suspicious connections based on shared personal attributes. FICO analytics can then determine and prioritize the strength of the connections to identify new suspects.

FICO Identity Resolution Engine is a critical complement to FICO® Insurance Fraud Manager, an enterprise solution that addresses payment error issues, including fraud, waste and abuse (FWA), with out-of-the box adaptive predictive analytics. Insurance Fraud Manager forms the core of the FICO® Payment Integrity Platform, a fully integrated solution that dramatically improves claims processing throughput, payment integrity and compliance.

Insurance Fraud Manager uses FICO’s market-leading adaptive predictive models to analyze adjudicated, but not yet paid, claims—up to one million per hour. With it, health care payers are empowered to quickly stop FWA before or after payment, ending the vicious cycle of “pay and chase.”

Learn how your company can benefit from FICO’s advanced solutions to fight health care insurance fraud. Contact us at [email protected].

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Uncovering More Fraudulent Health Care Providers with FICO® Identity Resolution Engine