From healthcare and financial claims to insurance and product warranty claims, identifying and monitoring fraud and compliance is a priority for every organization. It is not only the monetary loss at stake, but also the potential damage to a company's reputation and trust. However, it can often be a challenge for companies to understand and stay ahead of ever-evolving fraud risks and proactively identify and investigate active threats—let alone to navigate the new world of robust data analytics to assist in the process.
At Elder Research, our primary goal as an analytics consultant is to help our clients fraud and compliance departments achieve greater performance, efficiency, and return on investment. We employ unique data science methodologies and analytical techniques to build and deploy effective fraud detection solutions.
Elder Research maintains deep experience in the following application areas for fraud detection:
- Contract fraud
- Pharmacy fraud
- Healthcare fraud
- Insurance claims fraud
- Anti Money Laundering (AML)
- Tax fraud
- E-commerce transactions
We begin each fraud detection solution with a careful evaluation of the client’s existing business process and industry best practices. Guided by our expertise and industry insight, we identify potential sources of fraud origination while collecting cases of fraud identified by auditors, investigators, and others within the existing manual processes. With this information we can design metrics for measuring fraud and work with our clients to automate the discovery process. The result is a deployed fraud detection system that looks at the entire business sequence, uncovers patterns of suspicious behavior, and provides actionable alerts to the organization.
The return on investment for effective fraud detection solutions can be transformative. Fraud prevention, recovery and restitution results in immediate savings, and once our clients begin to use the tools successfully, the results can provide insight for their long-term strategic planning.
RADR Risk Analysis Platform
To meet the needs of customers in the contract fraud and healthcare fraud areas, Elder Research developed the Risk Assessment Data Repository (RADR) risk analysis platform. This tool uses predictive models to score contracts and healthcare claims for their likelihood of fraud, waste, and abuse based on a customized set of risk indicators. RADR then delivers the results using a powerful web-based interface.
RADR allows our team to quickly build customized risk scores and data visualizations solutions that fit our client’s unique industries and operational environments, rather than trying to fit their data to canned analytics software solutions.
Fraud Analytics Case Studies
Our clients—whether newly formed analytics teams or established professionals—find that we help them understand their data, strengthen their teams’ abilities, and bring to the forefront basic and advanced levels of analytics insights aligned to their needs. Examples of our fraud, waste and abuse solutions include:
Targeting Questionable Contracts and Healthcare Claims to Detect Fraud, Waste, and Abuse
The U.S.Postal Service Office of Inspector General initiated fraud investigations based mainly on tips they received. To be more proactive, the agency sought to create a systematic process to provide investigative analysts with data-driven leads based on known fraud schemes. Elder Research partnered with the USPS-OIG to develop and deploy a custom fraud detection solution to identify and prioritize questionable contracts and healthcare claims for investigation.
Results: The fraud solution generated over $11 million in recoveries, restitution, and cost avoidance in the first year and has since contributed to $920 million in findings. Read the Case Study
Improving Workers' Compensation Provider Fraud Detection
The client, a national Workers’ Compensation Insurance Program, handles almost 200,000 claimants who are currently receiving medical compensation for services rendered by tens of thousands of medical providers. They wanted to improve the efficiency of their fraud analysts by using analytics to detect high-risk cases for further investigation. Elder Research designed and deployed an automated fraud detection and visualization solution to improve the efficiency of fraud detection and investigation by prioritizing high-risk cases. Investigations and forensic analysis that took hours can now be completed in minutes, making the most efficient use of limited and valuable resources. Read the Case Study
Reducing Service Provider and Warranty Fraud
Warranty fraud directly impacts profits and the public perception of companies and their service partners. The warranty department for an industry-leading computer technology provider needed to reduce return rates and proactively identify cases of warranty fraud or claim anomalies indicative of fraud among its service provider base. Elder Research designed, prototyped, piloted, and deployed an automated fraud detection solution.
Results: The solution is credited with saving over $67 million in service provider and warranty fraud. Read the Case Study