Leverage the power of multiple entity risk
Any fraud, waste and abuse system is only as good as the most updated data feeds and learned behaviors of the newest schemes and sources of the bad actors.
As such, antiquated rules-based linear approaches no longer keep up with their innovations and newfound attacks.
What’s in it for you?
ElectrifAi’s FWA system leverages the power of multiple entity risks and uses advanced machine learning techniques, pattern recognition algorithms, and artificial intelligence to achieve measurable and tangible results.
Using Physicians and Facilities risk scores, coupled with clinical and claim details we continually re-evaluate the entities’ risk and their interactions to feed the outlier detection process.
We have been working with the Centers for Medicare and Medicaid Services (CMS) since 2012 to assist them with payment and program integrity. In that time, we've been helping to provide clinical detection of program level over-payment to help CMS maintain the integrity of the overall program. Our data solutions aggregate, analyze and validate over 50 million payment records monthly and have verified over 106 million enrollment records.
We evaluate and learn from many data sources to reveal suspicious, hidden connections between members, doctors and claims across their programs. All aspects of the system are built to handle the massive data sets found in healthcare to help in determining a claim outlier which reduces false positives and allows for prioritizing the highest risk claims.
With unparalleled accuracy, payers can properly prioritize, optimize staffing and investigate potential fraud (both pre-pay and post-pay) more efficiently to:
- Meet regulatory requirements
- Reduce risk of marketplace enrollment fraud
- Protect against fraudulent claims and identity-based fraud
- Reduce false-positive rates to improve Provider relation
- Accurately link providers, members and claims
- Quickly uncover complex fraud schemes
- Discover previously unknown relationships among the individuals and businesses that warrant fraud investigation
- Identify potentially fraudulent providers and businesses enrolling in programs