Pega Marketplace
Healthcare Fraud Detection using Pega Process AI
HealthCare Fraud Shield
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Overview
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.
Key Features
- Score card Model
- Fraud Claim Identification
- Intelligent Automation
- Customizable Fraud Detection Strategies
- Dynamic Fraud Probability Scoring
- Real-Time Decision-Making
- Intelligent Claim Routing
- Continuous Adaptive Learning
- Seamless Integration with Pega Process AI
- Enhanced Operational Efficiency
Resources
Partner Name
Maantic
Tags
- Pega Products: Pega Smart Claims Engine for Healthcare Pega Process AI
- Industry: Healthcare
- Product Capability: Low-Code App Development Artificial Intelligence
- Pega Version compatibility: Pega Platform '23 8.8 8.7
- Geography: Americas
Offering Type
Component