METHOD AND SYSTEM FOR REDUCING DEPENDENT ELIGIBILITY FRAUD IN HEALTHCARE PROGRAMS

摘要

The present invention provides a system and method for reducing fraud in a healthcare benefits plan using a predictive model to identify those subscribers having a high probability of maintaining an ineligible dependent under the plan. The predictive model may be developed using subscriber data of the subscriber group being analyzed or using a base case subscriber group having certain similarities to the subscriber group being analyzed. In accordance with the present invention an analysis engine receives subscriber data of subscribers in a subscriber group, which includes data of at least one subscriber reported to have maintained an ineligible dependent under the healthcare benefits plan, and develops a predictive model using the subscriber data. A predictive engine applies the subscriber data to the predictive model. A reporting component then uses an output of the predictive model to report a score for at least one subscriber of the healthcare benefits plan, wherein the score indicates a probability that the subscriber is maintaining an ineligible dependent under the healthcare benefits plan.