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Using Big Data to Easily Identify Fraud with Zelis

When healthcare technology company Zelis needed a Big Data solution to easily identify fraudulent claims, Redapt’s data scientists provided Zelis with a framework.

In a nutshell

The problem

Zelis needed a Big Data framework for identifying potential fraud in millions of insurance claims.

The solution

Redapt built a platform that allowed Zelis to run models based on historical data to pick out suspicious claims.

The outcome

Zelis employs a flexible rules engine to help the company stay in front of new trends and areas of fraud so they can focus on outcome-based healthcare.

Moment of clarity

By building a framework for our data scientists to run various models, Redapt developed nearly 50 distinct ways for Zelis to process claims and identify potential irregularities based on mountains of data.

What the company needed

A core part of Zelis’s business is processing out-of-network claims between doctors and insurance providers. Flagging cases of fraud, waste, and abuse (or FWA) is a major challenge when millions of claims are being processed from hundreds of different providers.

To keep up with the never-ending stream of data, Zelis needed the ability to predict and isolate potential fraudulent claims—a classic needle in the haystack scenario.

Our recommendation

  • A framework for efficiently sifting through data to identify and fingerprint historic costs related to procedures.
  • A flexible rules engine that can be modified with new information derived from a constant stream of data.
  • Leveraging Microsoft Azure for data scientists to run data models efficiently and with far less resources than on-premises.

The end result

  • Ability to continually improve algorithms

    in order to stay ahead of new trends in fraud and abuse.

  • Single pane of glass visibility

    for data model outcomes based on hundreds of different providers.

  • Accelerated processing

    of non-fraudulent claims.

Contact us to gain a little more clarity

We love a challenge. Tell us about your needs, goals, and the obstacles in your way. We’ll help you find solutions to get past them.

Get in touch directly:
(425) 882-0400