IBM's Fraud and Abuse, Analytics and Management Solution

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1 Government Efficiency through Innovative Reform IBM's Fraud and Abuse, Analytics and Management Solution Service Definition Copyright IBM Corporation 2014

2 Table of Contents Overview... 1 Major differentiators... 2 Main Product Features... 2 Main technical features... 2 Use Cases... 3 Example use cases... 3 Information assurance and Security... 3 Service options and SLA's... 3 Pricing Structure... 3 Overview of pricing structure... 3 Free trial options... 4 Further information... 4 IBM Corporation 17 December 2014 i

3 OVERVIEW IBM's Fraud, Abuse and Analytics solution combines IBM Global Business Services, the Fraud and Abuse Management System tools and IBM software products to deliver capabilities to solve key challenges associated with Fraud, Waste and Abuse. The solution is quick to implement, flexible and adaptable, and adheres to industry open standards. The solution can sort through information from tens of thousands of providers and millions of claims, bringing to information on possible offenders who might not have been identifiable any other way. The system sensitively can rank providers in relation to their peers within specific geographic regions, specialties and sub-specialties, and virtually any other parameters users choose to define. Figure 1: xxxx Offering highlights Organisations are struggling to keep pace with the rapidly evolving fraud schemes in highrisk areas of healthcare claims. IBM's Fraud, Abuse and Analytics solution enables organizations to use advanced data mining technology to identify claims at risk and assist with cost recovery. The IBM Fraud, Abuse and Analytics tools powers the solution, providing pre-built behavioural models developed and updated by leading industry experts, so that clients can quickly identify and pursue these areas of risk. IBM Corporation 17 December

4 Major differentiators The IBM Fraud, Abuse and Analytics models have proven results and realized savings. Innovative fraud detection methods: IBM is continuing to develop innovative methods for fraud detection - most notably, the use of maps and geospatial analysis to find fraud. Use of historical claims data: IBM uses historical claims data in our prepayment fraud solution. Lower false positives: The IBM Fraud, Abuse and Analytics solution minimizes "false positives" by leveraging proven specialty specific behaviour models. Immediate Savings: IBM's solution provides clients with immediate savings/roi within the first six months. Retrospective and Prepayment Analysis: IBM's proposed solution includes retrospective and prepayment claims analysis capability. Integration: IBM has proven integration capabilities with multiple solutions/organizations.. MAIN PRODUCT FEATURES IBMs' Fraud, Abuse and Analytics solution can: Handle Large volumes of data Advanced Techniques for Big Data Quickly understand large and complex datasets using advanced statistical procedures to provide high accuracy and drive quality decision making. Manage meaningless data in its raw state Automated Data Preparation - Streamline the data preparation stage of the analytical process to deliver faster, more accurate data analysis results. Assess unstructured data is often ignored Holistic Approach to Data Utilise analytics on unstructured data (text, social media, natural language processing) for completeness of insights into the data. Provide access to domain specific sources Data-agnostic Approach Utilize insights from all data. Determine what is "normal" Outlier Identification Quickly define what is normal and what is an anomaly through statistical algorithms. MAIN TECHNICAL FEATURES COGNOS 8 BI provides Fraud, Abuse and Analytics reporting functions WebSphere Application Server Express provides thin client (web browser) access into the Fraud, Abuse and Analytics Solution, a function that is critical for fraud investigators in the field ILOG for pre-payment capabilities DB2 Workgroup provides database functions for the user client workstation. IBM Corporation 17 December

5 USE CASES Example use cases The Fraud, Abuse and Analytics Solution can: Detect multiple behaviours and schemes simultaneously Move analysis from claim level to provider level Shorten the time to investigate and recover funds Measure fraud scientifically Using the solutions Diagnostics, you may be able to: Understand your highest risk area Get cases with detailed understand of the reason for selection Get a positive ROI from the diagnostic work Shortens the time to investigate and recover funds Measures fraud scientifically Using the FAMS Diagnostic, you can: Obtain a thorough analysis of your highest risk area Get tangible cases with detailed reason for selection Get a positive ROI from the diagnostic work. INFORMATION ASSURANCE AND SECURITY The tailored architecture allows for services to be deployed within most environments. Data does not leave customers domain IBM staff are Security Cleared and based in the UK. SERVICE OPTIONS AND SLA'S Includes options such as availability, backup and recovery, performance, etc. PRICING STRUCTURE Overview of pricing structure A range of price deals, that include the Asset exist. It is expected that services will be required to configure, install and tailor the assets to your environment under the IBM Standard Terms and IBM Corporation 17 December

6 conditions. The preferred delivery approach is to assess what is required through a Business Value Assessment (BVA) using the standard IBM Service Rate Card. This should determine the full pricing for the solution. Free trial options Not available. FURTHER INFORMATION An intuitive visual interface that helps users build predictive models quickly without programming. Model capabilities such as : Data Preparation, anomaly detection, Classification, regression, time series, segmentation, association, and linear modelling. Modeler Premium enables users to incorporate unstructured information into the predictive analytics process. Share analytic assets in a controlled manner by utilizing a centralized repository. Facilitates the deployment of models into business processes using real-time scoring. Finally, it monitors and manages models to ensure there is continuous improvement and refinement for best results. A decision process framework that uses predictive analytics and business rules to operationalize and optimize decisions. Minimal learning curve thus of significant value to both business analysts and statisticians predictive analytics accessible to multiple user types and skill levels High levels of satisfaction with the data access, data filtering and manipulation, advanced descriptive analytics, predictive analytics, user experience, and the performance and scalability components of the product. IBM Corporation 17 December

7 IBM United Kingdom Limited PO Box 41 Western Road North Harbour Portsmouth Hampshire PO6 3AU Date: 17 December 2014 Version: 1.0 IBM Corporation 17 December

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