In every industry and region, fraud remains a persistent and growing threat. The Association of Certified Fraud Examiners (ACFE) estimates companies lose 5 per cent of revenues each year to fraud in its many forms. That equates to an astounding $3.7 trillion in collective losses annually. Organisations that lack anti-fraud controls suffer twice the median losses.
In the era of big data, advanced data analytics have become an indispensable part of the fraud-fighting equation – and SAS is at the forefront of fraud analytics. As a sponsor of International Fraud Awareness Week Nov. 11-17, SAS joins the ACFE in encouraging organisations to understand the schemes that put them at risk and strategies for thwarting them.
“As fraudsters get more sophisticated, SAS helps organisations get more sophisticated at fighting back,” said Stu Bradley, Vice President of Fraud and Security Intelligence at SAS. “It’s not enough to simply keep up with the bad actors. The latest analytics and adaptable machine learning and AI capabilities built into SAS’ fraud and security intelligence solutions help organisations stay a step ahead.”
Detecting fraud, waste and abuse in prescription drug claims
Fraud, waste and abuse (FWA) cost health care systems tens of billions of dollars annually. Earlier this year, Eagan, Minn.-based Prime Therapeutics became the first pharmacy benefits manager (PBM) to integrate pharmacy and medical drug claims with medical service data in a comprehensive fraud-detection platform, which includes an integrated case management system.
Powered by SAS®, the analysis of this data helps Prime detect fraud occurring among prescribers and members, in addition to pharmacies. For example, it can help identify members who get prescriptions through insurance fraud, identity theft, or collusion with a pharmacy or prescriber. The platform can also find prescribers who falsely diagnose patients, receive kickbacks for certain medications or submit duplicate claims. Prime estimates the new fraud platform will help them root out more than $265 million in FWA in the next year.
“Most fraud, waste and abuse investigations are conducted in silos by platforms or organisations that don’t work together,” explained Jo-Ellen Abou Nader, Assistant Vice President of FWA Operations at Prime. “And while many PBMs and health plans may have pieces of data, integration of that data is what makes it most useful and efficient. The enhancements we will achieve through this SAS tool leapfrog Prime to the leading PBM in counteracting fraud, waste and abuse for health plans. Partnership in the industry, including with our health plan clients and our fraud analytics vendor SAS, is critical to fighting fraud. The key to success is obtaining fraud analytical outliers early to investigate, collaborate and consult with our clients to take action and achieve favourable outcomes.”
Preventing financial crime and ensuring regulatory compliance
Money laundering through banks by organised criminals is a growing global concern, resulting in increased regulatory pressure. Banks face the same legal requirements for anti-money laundering (AML) regardless of size, which gives larger banks a significant resource advantage.
To help even the playing field, Danish IT service provider SDC provides its banking clients a communal service model based on SAS Anti-Money Laundering and other SAS solutions. The offering helps 120 small- and medium-sized Nordic banks comply with AML regulations and monitor suspicious activity with a centralised governance and oversight system. This saves the banks significant resources, while still allowing individual tailoring for each client’s specific needs.
“At SDC, we have been thinking eight to 10 years ahead,” said Suzan Moos, Business Analyst and Developer at SDC. “We are really one of the first technology partners in the world that can provide smaller banks the quality of anti-money laundering surveillance that only the largest players in the financial market would otherwise be able to muster.”
Fighting Medicaid fraud with analytics
Medicaid fraud, waste and abuse costs states billions of dollars each year, diverting precious funds needed for legitimate health care. At a recent SAS Government Leadership Forum, a panellist from the US Centers for Medicare and Medicaid Services (CMS) shared how the agency is using advanced analytics for program integrity and efficiency. By analysing billing and other data, CMS identifies likely improper payments and presents information to leadership through an analytics dashboard. The presentation can be viewed via the forum’s archived livestream.
“As the Ohio Medicaid Program Integrity Director, I saw the benefits of CMS committing to a data-driven culture,” says John Maynard, SAS Fraud and Risk Specialist for Health Care and Government. “In addition to better Medicaid data quality, the commitment led to improved provider enrollment, provider education, audit services, fraud prevention, recovery and fraud training.”