Link analysis is a data analysis technique that investigates the relationships between different entities in an ecosystem. This technique offers a visualization of links between entities for an intuitive and accurate understanding of how fraud is being perpetuated. This visualization of complex links between networks would otherwise be difficult to discern or explain to others.
Insurance ecosystem data is too vast and telling a story with words and numbers is seldom very effective. Links analysis offers clear, easy visuals that allow you to make sense of all the underlying data and tells the story very quickly. If the story looks persuasive, you can advance the issue quickly rather than discovering fraud after months or years.
Traditional outlier detection models don’t work
Statistical models can identify fraudulent claims but may also return many false positives. A better technique is to delve deep into claims data to find links that can point to fraudulent claims and support that with other insights. This can minimize the number of false positives by guiding you towards red flags that offer a high probability of fraud.
Link analysis shows patient/provider relationships and how facilities are clustered around the claimant. This visualization can help identify suspicious billing patterns or quantify data anomalies.
From the context of worker’s compensation fraud, links analysis may provide a visual representation of connections between providers and facility providers, shared facilities, phone numbers and addresses.
1. Detecting misrepresentations in locations of service
Link analysis offers a map, graph or tabular view of the distance (miles) between the claimants and facilities. Consider a case where the location of service has been misrepresented to forward what is not considered a reimbursable expense by insurers. You can visually observe how often the claimant visits the clinic and the distance between the two entities. The visualization can be as simple as colored lines connecting entities or clusters of providers or facilities in a particular zip code.
2. Understanding the involvement of multiple perpetrators
Worker’s compensation fraud perpetuated by multiple providers can be very costly. The fraud may come to light after many years. Link analysis can prevent the fraudulent practice from continuing indefinitely by investigating suspicions in an informed way.
Fraudulent entities are more likely to be connected to other fraudulent entities. Link analysis can remove the lid on not one but multiple perpetrators. Imagine a scenario where five healthcare professionals, including specialists, a health care marketer and a hospital CEO engage in personally-enriching patient referrals in exchange for kickbacks and inflate the cost of implants used in surgeries. The hospitals bill your insurance company and the Department of Labor.
If, at any point, a red flag comes up or a patient files a complaint in the Attorney General’s office, then link analysis will come in handy in the proceeding investigation. You will be able to view links between networks with a single glance. If many links emanate between a particular hospital and one or more specialist located far from the patient’s residence, then you can very soon identify all participants of fraud.
3. Getting more information on suspicious entities
An advanced analytics software offering link analysis will also provide more details on a suspicious entity. By design, machine learning-powered fraud detection solutions maintain comprehensive and up-to-date information on providers, including addresses and phone numbers. You can get in touch directly with entities to ask questions or gain clues that can strengthen your suspicions or require you to collect more evidence before making a formal charge.
By providing patterns and links between different networks, link analysis serves as a valuable functionality in proactive fraud detection.
The Aquilla platform leverages Artificial Intelligence and Machine Learning to assess healthcare data for suspicious patterns and proactively detects workers compensation fraud, Saving Insurance Companies Millions of dollars and weeks or work.
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