Imagine protecting yourself and your customers from healthcare fraud, waste and abuse
Fraud, waste and abuse (FWA) is a $240 billion problem in the U.S. When fraudulent claims are paid, healthcare insurers are left out of pocket, trying to be reimbursed after payment. Estimates are that only five to ten percent of fraud is intercepted, according to the National Health Care Anti-Fraud Association. With increasingly complex schemes, it’s getting harder to eliminate FWA with traditional payment integrity solutions.
Mastercard® Healthcare Solutions is building on its long-held success in healthcare payments to address FWA. With the same advanced fraud prevention technologies that it uses for the financial services industry and governments around the world, Mastercard AI helps payers detect erroneous or fraudulent claims — before reimbursing providers. Artificial intelligence (AI) models can be tailored to identify healthcare claims fraud, prescription abuse, upcharges, phantom billings, and many other FWA challenges.
Our Smart Agent technology creates an end-to-end suite of profiling and modeling capabilities that continuously adapt and improve results. This seamless combination of advanced AI tools delivers personalized decisions in milliseconds to payers, insurance companies, federal or state governments, payment processors and other payment integrity vendors. Evolving models scale with your data, increase detection rates, and decrease operational costs and false positives.
Prevent and save: advanced AI for fraud, waste and abuse
Download the Ebook to learn how:
- Advanced AI supports pre-pay, so you can prevent fraud before a claim is paid
- Proven AI fraud prevention technology is being applied to healthcare fraud, waste and abuse
- Higher detection rates and fewer false positives let you focus on more complex FWA
Features and benefits
- Created by an experienced, innovative company with proven fraud prevention technology
- Provides accurate post-pay data analysis to “prevent and save”
- Complements and supports special investigation units (SIUs) and other payment integrity partners
- Combines the right tools to create a unique AI model for each customer’s needs
- Receives any data, in any format
- Allows real-time insights: upload time less than 10 ms (high throughput response time)
- Provides extraordinary scalability, twice that of our closest competitor (Aite Group analysis)
- Builds your unique AI model in 6-8 weeks with AI Express
- No database requirements: our distributed file system guarantees no single point of failure
- Automatic updates to the AI model based on actions taken, identifying changing behaviors
- Have peace of mind, security and longevity
- Get early ROI: detect and prevent fraud before claims are paid to avoid “pay and chase”
- Have increased operational efficiency: Focus on actual FWA and complex cases
- Solve targeted business problems
- Get instant insights and efficient claims processing
- Prevent more fraud with proactive defenses that adapt to change in real time
- Have a technology that grows with your business, future-proofing operations
- Be ready to deploy and see immediate ROI
- Stay immune to failure and disruption
- Be ready to adapt and stop ever-changing fraudulent behavior
Use case: FWA
The healthcare industry loses tens of billions of dollars each year to fraud alone (National Health Care Anti-Fraud Association). Insurers detect only a small fraction of suspicious claims, resulting in rising healthcare costs and higher premiums for patients.
Healthcare insurers are largely pursuing suspicious claims post-adjudication—with the result that they recover only a small percentage of these lost dollars. Compounding the challenge, analyzing
large amounts of healthcare data is complex and many insurers lack the time or resources to do so. Fragmented legacy claim management systems make the task even more difficult.
It comes as no surprise that insurers’ fraud investigators are overwhelmed with alerts and struggle to keep up. The bottom line for insurers: complex contracts, coding, management costs and regulations are limiting profits and compressing margins.
Mastercard’s artificial intelligence (AI) can create prospective (pre-pay) models built by identifying anomalies found in historical claims data (post-pay). The pre-payment model identifies FWA before the insurer sends good money for bad claims, significantly reducing the need for inefficient pay-and-chase activities.
Since the technology enables live updates to existing models based on real-time claims experience, Mastercard AI reduces “digital noise” and automates some of the manual processes involved in maintaining and updating existing rule-based technology.
“Organizations can expect a very strong return on their investment from us because we’re coming in with an extremely strong, proven technology that can drive up their detection rates and drive down their false positives. Mastercard AI allows the investigators who are working those claim files to focus on the things that really matter.”
Vice President, Healthcare,
Product Development and Innovation
Customized AI models use historical data, as well as third-party sources to ensure immediate savings. This and future data can be received from any source, in any format, and can be enriched using both AI and machine learning. Unsupervised and supervised learning improve outcomes over time, creating pre-pay AI models that grow and mature with the everchanging behaviors of fraudsters.
With increased detection of true FWA, false-positives are greatly reduced, and insurers can focus their investigators’ time on highly-likely fraud, waste or abuse.
Collaboration & innovation
We provide a complementary AI solution that does not replace but integrates and improves outcomes for payment integrity providers and SIUs. Our technology uncovers complex schemes that other approaches haven’t been able to identify.
Customers can enjoy the ability to work with our specialized healthcare team and leverage other Mastercard innovative technologies such as:
- Identity detection for authentication of providers or patients
- Predictive analytics to make more accurate decisions as you innovate
- Cybersecurity solutions to mitigate data breaches that have an adverse impact on health care companies and patients
Mastercard AI updates event profiles to stay current with trends, providers and healthcare practices. This innovative practice enables fraud detection before claims are paid.
“We’re bringing a very collaborative, innovative partnership to change the face of healthcare fraud, waste and abuse. It’s part of our DNA at Mastercard to be innovative and to really focus on our clients, trying to make their results have a bigger impact for their organizations.”
Vice President, Healthcare,
Product Development and Innovation
“It has been fantastic being able to talk to the Mastercard team when we face some challenges, or if we have a very nuanced question. We have a resource to go to to get that answered.”
Director of Innovation
Cambia Health Solutions
“Because they have a healthcare team that specializes in what we do, they have a better understanding of that than most of the vendors we work with.”
“I think historically, Mastercard’s healthcare vertical is a differentiator when comparing them to their competition.”
VP of Innovation and Growth
Optum Financial Services
“Mastercard is a clear leader in healthcare payments. We share the mission to enhance consumer value for the industry. They are the best partner to accelerate our business growth.”