FICO Equips Healthcare Insurance Payers to Detect New Forms of Fraud in ICD-10 Claims
SAN JOSE, Calif., July 11, 2013 /PRNewswire/ — FICO (NYSE:FICO), a leading predictive analytics and decision management software company, today announced that FICO(®) Insurance Fraud Manager, the most advanced system for detecting and preventing healthcare insurance fraud, waste and abuse, now natively supports International Classification of Diseases, 10(th) Edition (ICD-10). ICD-10 is the new diagnostic coding system implemented by the World Health Organization for healthcare resource allocation and reimbursement. By natively supporting ICD-10, FICO Insurance Fraud Manager will help payers make a smooth transition to the new coding system, continue to accurately detect fraudulent claims, and pay legitimate claims with greater confidence.
With the upcoming move to ICD-10, diagnosis codes will grow in number from roughly 18,000 to more than 55,000 globally and 140,000 in the U.S. The transition is complicated in the U.S. because providers are paid by procedure. Misuse of ICD codes can lead to one type of fraud known as upcoding, where providers use the higher-fee codes to charge the healthcare insurance payers for lower-fee procedures or, in some cases, services not rendered at all.
FICO Insurance Fraud Manager can now automatically access and process ICD-10 diagnostic codes, spotting unusual clams and unusual provider billing, and scoring and ranking these outliers by how far they depart from usual behavior patterns. The models used in FICO Insurance Fraud Manager instantly detect problems that rules and queries alone miss, enabling insurance healthcare payers to save money by not paying illegitimate and incorrect claims, while increasing throughput by automatically settling the vast majority of legitimate claims.
“Given the dramatic increase in the number and complexity of diagnostic codes, the new classification system provides an opportunity for fraud through new combinations of diagnosis and procedure codes not previously defined in rules-based fraud detection systems,” said Russ Schreiber, vice president for the insurance market at FICO. “FICO Insurance Fraud Manager relies on analytic detection that’s based not only on what happened in the past, but also on what is happening currently, so it finds more fraud under changing conditions than rules-driven detection. That way, payers can avoid the messy transition to ICD-10 that would otherwise open the door to an entirely new breed of claims fraud and abuse.”
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