Fraud, Waste, and Abuse Ontology
Many U.S. healthcare insurers and providers lose millions of dollars annually to fraud, waste, and abuse (FWA). An estimated four to ten percent of all health insurance claims contain fraud, waste, or abuse. CTG’s unique ontology-based approach to detecting FWA can dramatically improve FWA identification, significantly lower FWA losses, and minimize the impact of FWA on payer and provider bottom lines.

We employ a new generation of business intelligence software with an advanced targeting methodology that builds a comprehensive multisource knowledge base that identifies FWA patterns for investigation. Our FWA team brings together experienced experts in FWA detection from the public and private sectors, hospital clinicians and administrators, and technologists with significant healthcare and insurance industry knowledge. CTG’s FWA solution efficiently identifies FWA at rates that materially exceed those of standard brute force data mining approaches currently used by those in the healthcare and insurance industries.

• Applies advanced business intelligence to model and target FWA
• Uses ontology-based model to build a comprehensive FWA knowledge base integrating provider and payer claim codes, medical expertise, and provider data to flag FWA and recommend actions
• Implements advanced rules-based FWA targeting

Client Benefits

• Provides a flexible, scalable system for new forms of FWA
• Facilitates evidence collection and case building
• Facilitates revenue recovery and case tracking
• Provides advanced health insurance knowledge base
  interfaces to existing systems
• Achieves higher recovery rates than standard methods

Identifying Fraud, Waste, and Abuse