Fair Isaac Announces Payment Optimizer 2.5, Bolstering Fraud Detection and Payment Integrity for Pharmacy Claims

MINNEAPOLIS – Fair Isaac Corporation, a leading provider of analytics and decision technology, today announced the release and immediate availability of Payment Optimizer® 2.5 solution, an enhanced version of its fraud detection system for healthcare payers that provides prepayment and postpayment analysis to dramatically reduce fraud losses and ensure payment integrity.

Version 2.5 adds pharmacy data and analyses to help detect suspicious activity and billing and policy errors in pharmacy claims at the point of sale, prior to payment or immediately after payment. This new feature will assist healthcare payers in managing steadily escalating costs and the anticipated surge in utilization when Medicare Part D of the Medicare Modernization Act becomes effective January 1, 2006. Part D will make voluntary prescription drug benefit available for the first time to more than 40 million Medicare beneficiaries.

“Part D creates complex new challenges for payers, pharmacies and patients, which will require the use of sophisticated analytics to analyze the voluminous amount of data from the multifaceted healthcare delivery and payment system,” said Dr. Andrea Allmon, director of healthcare operations and product management of Healthcare Solutions at Fair Isaac. “With the addition of pharmacy analyses to Fair Isaac’s Payment Optimizer solution, payers can assess fraud risk in both pharmacy and medical claims, and obtain a comprehensive picture utilizing both claims sources to find even more fraud, abuse and errors.”

By analyzing millions of interactions in a fraction of a second, using both incoming and historical data, Payment Optimizer 2.5 creates a multidimensional picture of the healthcare and pharmacy delivery system. Users can quickly identify fraudulent activity, including fraud types that previously could not be detected. Fair Isaac’s proprietary advanced analytics enable accurate and efficient detection of new and unknown fraud patterns as well as subtle and complex trends by looking at each claim in relation to deep contextual information, such as the patient’s and provider’s histories. The Payment Optimizer solution is as powerful in containing costs as it is in identifying sophisticated emerging fraud and abuse schemes.

“Payers need to be better prepared for the growth of claims anticipated by the aging of the population, with a concomitant increase in per capita use of prescription drugs, and the additional claims to be driven by the advent of Part D on January 1,” said Joanne Galimi, director of research at Gartner, Inc. “These new prospective technologies and approaches will not only detect fraud and abuse, but will assist in the prevention of lost funds.”

The National Healthcare Anti-Fraud Association estimates that up to 10 percent of every dollar spent on healthcare is lost to fraud, abuse and error, draining the system of $170 billion a year. Preventing these losses could reduce consumer costs, reward shareholders and lead to improved treatments. To date, Payment Optimizer users have achieved a return on investment (ROI) ranging from 3:1 to 10:1, and have seen average savings of $25 to $30 for each claim reviewed, while taking 30 seconds to three minutes to review a claim.