Building on a history of collaborative successes, Sun Microsystems, Sybase and SPSS have announced Predictive Fraud Detection for Healthcare, an analytical business solution to help private healthcare organisations detect and combat fraud. The solution minimises risk by detecting claimant and provider fraud using predictive analytics.
Since the early 1990s, healthcare fraud - the deliberate submission of false claims to private health insurance plans and/or tax-funded health programmes - has been viewed as a serious and still-growing crime phenomenon, linked directly to ever-growing annual healthcare outlays.
The solution is based on industry fraud detection best-practice templates currently used to enable healthcare organisations to quickly detect a wide range of fraud.
Such fraudulent activity includes duplicate claims submissions; unbundling (submitting a claim for each procedure when only one is required); and ping-ponging (the sharing of a single patient ID to generate billings across multiple providers).
The fraud detection solution can also help predict which medical practices within a provider base are most likely to be out of compliance, and identify claimants who are most likely to commit fraud.
"Every year, healthcare fraud creates enormous losses in a system that can ill afford to be losing any amount of revenue," said William Mahon, president and chief executive officer at the National Health Care Anti-Fraud Association (NHCAA) in the US. "We estimate annual loss to fraud for the healthcare industry to be between three and ten per cent of total healthcare revenues. With US national healthcare spend at $1.4 trillion in 2001, that translates to annual losses somewhere between $42 billion and $140 billion for the industry."
"Healthcare claim payers are taking strong action to combat fraud and abuse of the system in key areas, and analytic applications play a critical role in this effort," said Scott Zahl, vice-president, Sun Business Group, GE Access.
"The Sun, Sybase and SPSS solution, integrated and distributed by GE Access, provides the healthcare industry with a finely tuned and proven template for detecting and analysing patterns of fraud in large corporate data warehouses. Preventing such fraud, we believe, will help combat a problem that costs the industry - and taxpayers - billions of dollars a year. We plan to replicate this template in a variety of other industries that will help grow our solution providersâ business, and we look forward to collaborating with Sun, Sybase and SPSS on that continuing effort," he continued.
The Predictive Fraud Detection solution is comprised of Sun Fire V480 and V880 servers, Sun StorEdge arrays and the Sybase Adaptive Server IQ Multiplex enterprise analytical engine - optimised for performance with SPSSâ data mining workbench, Clementine and the Clementine Application Template (CATs) for fraud detection.
Availability and Support Working with Sybase, SPSS and Sun, GE Access will integrate, test and ship a complete plug-and-play solution for the healthcare market. Ultimately, this offering will expand solution providersâ ability to meet the needs of the healthcare industry and grow their own customer-base.
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