ClarisHealth Launches A.I. Powered Healthcare Fraud Detection Solution for Health Plans

ClarisHealth, the company transforming health plan operations with its comprehensive payment integrity technology platform Pareo, launched an artificial intelligence-based (A.I.) solution for healthcare fraud detection. Pareo Fraud Detection works seamlessly with Pareo Fraud Case Management for an integrated, 360-degree approach to mitigating fraud, waste, and abuse (FWA).

According to Mark Isbitts, vice president of program integrity for ClarisHealth, who led the project, Pareo Fraud Detection provides significant advantages over conventional tools that have been in use for decades. This traditional approach involves sifting through massive amounts of data and defining thousands of rules to detect fraud, which limits its scope of effectiveness.

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“Currently, the SIU deals with overwhelming numbers of false positives and manual processes and still may miss some aspects of fraudulent activity and new emerging criminal schemes,” says Isbitts. “Pareo Fraud Detection is based on our proven payment integrity technology platform and features a transparent and efficient user interface that provides a view of why a provider is marked as fraud and enables investigators to visualize different patterns and scenarios in just a few clicks – without inputting multiple rules. ”

Pareo Fraud Detection models were developed in partnership with data science experts from the College of Business Administration at the University of Illinois-Chicago (UIC). Kyle Cheek, PhD., the director of the Center for Applied Analytics and a clinical associate professor of Information and Decision Sciences at the university, has worked in various payer fraud organizations. He helped ensure the solution escaped a fundamental drawback of A.I.: lack of explainability.

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“An A.I.-based technique is not usually transparent about how it generates its outputs and is often referred to as the ‘black box,’” says Cheek. “However, Pareo Fraud Detection harnesses the power of deep learning applications of A.I. informed by domain expertise so the SIU will get information on which providers to investigate first, why a provider is suspicious, and how valuable the investigation can be – in real-time, efficiently, and with limited manual efforts.”

The release of Pareo Fraud Detection continues the ClarisHealth strategic direction of expanding the native functionality of the Pareo platform to maximize health plan cost avoidance and recoveries at the most optimized cost. According to ClarisHealth CEO Jeff McNeese, this approach is termed Total Payment Integrity™ and it transforms engagement with internal and external stakeholders.

“Just like there had been little innovation in payment integrity before Pareo, the same has been true for FWA solutions,” says McNeese. “Being able to solve payment integrity and FWA challenges end-to-end – from prepay to post-pay – on a single platform fulfills the Total Payment Integrity promise of Pareo.”

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