In most counter fraud processes, subject matter experts make the determination of the rules or scenarios around what should trigger a fraud investigation. Even if one has a supervised predictive model, that can only predict known fraud scenarios. Ayasdi’s technology automatically assembles similar groups of claims, providers, and patients. This allows the subject matter experts to uncover emerging unknown scenarios quickly.
A critical, often overlooked step, in Counter Fraud workflows is the ability to explain what has driven the creation of the anomalies and the optimization of thresholds within the scenarios. Aysadi provides complete transparency into what is driving the anomalous segmentation of claims/claims sequences/providers and the ranking and produces simple decision trees that can be shared with the investigation team.
Ayasdi’s Counter Fraud solution operates in a payer’s analytical workflow producing prioritized lists for the investigative team or into the appropriate downstream applications. Pushing intelligence to the subject matter experts results in fewer false positives and earlier identification of emerging fraud trends.
Ayasdi’s Counter Fraud solution is constantly looking at newly arriving data, identifying changing patterns and suggesting updates to segments and rankings based on that information. As a result, subtle patterns suggesting emergent behavior is identified for the subject matter experts to consider.