Fraud Detection Software

EmblemHealth's Special Investigations Unit (SIU) strives to prevent fraud and abuse.

EmblemHealth employs IBM's Fraud and Abuse Management System (FAMS), a state of the art software package that improves methods of detection and investigation. FAMS provides the SIU with a unique tool in its efforts to reduce financial losses due to fraud and abuse.

FAMS compiles claims data and ranks providers against peers in the same specialty groups. The SIU reviews provider billings and scores the data, creating a "report card" which identifies providers who fall outside the norms of their peer groups. For example, the report cards readily identify providers who routinely use more testing than others or treat more patients on non-work days. FAMS also helps the SIU to uncover member fraud and abuse by identifying suspicious behaviors in member histories.

This software gives the SIU instantaneous access to claims information that once took weeks to compile, resulting in more aggressive and efficient investigations.

The message is clear: providers and members who operate on less than honorable levels will not be successful at EmblemHealth!