Healthcare Fraud Detection using Pega Process AI

Healthcare fraud poses a significant challenge for payers, leading to substantial financial losses and undermining the integrity of healthcare systems. Fraud Shield, built on top of the Pega Smart Claims Engine and leveraging the enhanced decision management capabilities of Pega's Process AI, offers a comprehensive solution to this critical issue. By integrating advanced analytics, customizable fraud detection strategies & real-time decision-making, Fraud Shield effectively identifies and mitigates fraudulent claims, ensuring that payers can maintain financial stability and uphold compliance standards. Fraud Shield stands out with its dynamic fraud probability scoring, intelligent claim routing, and continuous learning capabilities. These features enable the system to detect suspicious claims with high accuracy and route them to skilled adjudicators for prompt review. The seamless integration with Pega's Process AI ensures that Fraud Shield remains adaptive to evolving fraud patterns.