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Products & Services

US Government Healthcare Fraud

Industry - Insurance
BAE Systems provides advanced analytics solutions for detecting fraud, waste and abuse in the United States government healthcare sector
Healthcare fraud, waste and abuse represent a significant and growing problem in the United States. Government healthcare programs need leading-edge social network analytics and predictive analytics to achieve a game-changing boost to the effectiveness of pre-pay and post-pay program integrity initiatives.

NetReveal for Healthcare Fraud solution

NetReveal®  for Healthcare Fraud solution from BAE Systems can operate in real-time to stop the cycle of “pay and chase” by blocking the payment of suspicious claims before the check is paid. Our solution considers every claim in the context of the history of the beneficiary and providers and takes into account any relationship to other parties.
Not only are current and future claims stopped, but the behaviour is automatically identified by the solution, allowing easy post-pay recovery of previous instances.

We are dedicated to helping our clients achieve unrivalled improvements both in the total volume of aberrant claims detected as well as in the accuracy of detection (reduction of false positives).

Key benefits

Our NetReveal Healthcare Fraud solution has been proven to provide the following benefits:
  • Provide holistic protection by detecting fraud, waste, and abuse that happened in the past (post-pay) as well as preventing it going forward (pre-pay)

  • Allow all program integrity efforts to be consolidated into a single intuitive case management and fraud detection solution that presents a holistic risk-profile for every claim, provider, and recipient

  • Maintain prompt payments – low risk providers and claims are able to be paid quickly, while resources can be focused on the highest risk cases via automated prioritisation

  • Prevent fraudulent and improper payments – risk assess every claim in real-time through integration with Medicaid Management Information Systems (MMIS)

  • Automatically search for patterns of relationships, changes and abnormalities in provider billing behaviour to identify suspicious activity

  • Risk assess every new provider at enrolment – take into account complex and hidden relationships to previously known actors

  • Significantly reduce time spent on investigations – using intuitive graphical tools and automatically generated case packs

  • Enable execution and measurement of strategic campaigns – including education, behavioural change and deterrent campaigns.