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If your customer base is a mile wide, sometimes its tough to detect fraud when its hidden more than an inch deep. The Government Employees ...

By Robert Regis Hyle | Updated on May 31, 2003

If your customer base is a mile wide, sometimes its tough to detect fraud when its hidden more than an inch deep. The Government Employees Hospital Association (GEHA) felt that way. GEHA is a national health plan serving federal employees, retirees, and their dependents. With subscribers spread throughout the country, traditional fraud detection systems werent doing the job for GEHA.

Bob Greene, manager of data analysis for GEHA, believes traditional fraud detection systems need a reasonable number of claims from the same healthcare providers to determine if those providers were being honest in their billing. We dont have a significant share of claims per physician, says Greene. For systems that are heavily dependent on rules, this was a significant problem we struggled with for a number of years.With policyholders so spread out and nearly half of their claims submitted electronically, Greene felt better detection was needed because adjusters were no longer handling the paper they once used and didnt get the feel of the paper claims.

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