IFM 4.0 Sneak Preview

FICO® Insurance Fraud Manager User Group: San Diego, CA | May 7--8, 2014 IFM 4.0 Sneak Preview Allyn Pon Senior Product Manager, IFMFICO

Insurance Fraud ManagerProficient • Extremely proficient workflow, providing information to make sound decisions quickly • Fingertip Data Mining – All drill-downpre-defined analysis available in a singleclick • Claim decisions in less than 5 minutes • Customizable case management • Scores provide relative priority, not just rank order • No analytic scientists needed – out of the box analytics immediately available P

Goals for 4.0 Ease of Use Access similar Scoring in same way Refesh UI across entire application Multiple Search Options in Multiple Screens Use Same Workflow for Claim Review Consolidate all Provider data in one place

Goals for 4.0 New Features Add Multiple Providers to a Single Investigation Integrated Facility Claim Review New Reporting Framework For Faster Response User Productivity Reports on Home Page Procedure Upcoding Analytic

IFM 4.0Home Page • Home page content is configured to each user role • Claim Reviewer (individual claim results) • Claim Reviewer Supervisor (team’s claim results) • SIU investigators (individual case list) • SIU Investigator Supervisor (team’s case list) • Left pane is configured by role, and provides access to different pre-defined dashboard reports for the user • Dashboard reports are designed to provide daily productivity feedback to the user and will vary based on the user role

IFM 4.0 Next Generation User InterfaceHome Page Consistent user-centric tabs Opens immediately tolast working page Quick selectionsmenu in left pane Note: These are early screen shots. Final screens will be similar but not exactly the same

Home Page Reports

IFM 4.0Review Claims • Maintain same workflow as before • Overall score added and useable for queue definition • Overall score = highest score of all the claim analytics • Provider score and Active Investigation Fields have been added* • Member Age based on the Claim Service Date is displayed • Same fields in used in each analytic detail is maintained from previous IFM versions

IFM 4.0 Next Generation User Interface:Review Claims Cascading Menus to Maneuver Quickly More Identifying Fields Including Score and Investigations No change in workflow Note: These are early screen shots. Final screens will be similar but not exactly the same

IFM 4.0 Next Generation User Interface:Review Claims Detail Note: These are early screen shots. Final screens will be similar but not exactly the same

IFM 4.0Facility Claim Review • Facility Out-Patient Analytics are reviewed at the claim line level, the same manner as Medical • Facility In-Patient Analytics are reviewed at the claim level • UI elements will be the same as the current implementation • Workflow remains the same as before • Claim Header • Claim Line Detail • Analysis Result • Action Section (Paid Full, Deny or Forward) • History Section

Facility Claims Review in 4.0 Note: These are mock screen shots. Final screens will be similar but not exactly the same

IFM 4.0Review Providers • Multiple View Options - Tile or Table Style Review • All Scoring Accessed Similarly – Provider (Peer-to-Peer) & Claim Scoring Rollups are accessed through the top menu • Convenient Search – Filter and Search in Left Pane • Easier Workflow – Everything about a single provider in one location • Profile • Summary of Financial Activity • Summary of Clinical Activity • Claims • Members • Drugs • Diagnoses • Procedures • Affiliates • Analytics

IFM 4.0 Next Generation User Interface:Review Providers – Cascading Menu Peer-to Peer Provider Scoring New Scoring Analytic Rollup Claim Scoring Note: These are mock screen shots. Final screens will be similar but not exactly the same

IFM 4.0 Next Generation User Interface:Review Providers Sorting and View Options Quick Search and Filter Tile or Table Format Note: These are mock screen shots. Final screens will be similar but not exactly the same

IFM 4.0 Next Generation User Interface:Review Provider Expanded Provider Summary • All provider information in a single location • Analytics and statistics easily available • More intuitive workflow Note: These are mock screen shots. Final screens will be similar but not exactly the same

IFM 4.0Review Procedures • New Tab • Previously known as Systemic Patterns located in the Reports section • Buried in the back but valuable report • Procedure Analysis – Scoring each Procedure for aberrant behavior

IFM 4.0Investigations • Listing of investigations listed by: • Active Investigations • All Investigations • Closed Investigations • More visible fields in the header summary • Same fields and functionality as previous IFM versions

IFM 4.0 Next Generation User Interface:Investigations Quick Selection For Investigator Home Page Hyperlink Note: These are mock screen shots. Final screens will be similar but not exactly the same

IFM 4.0 Next Generation User Interface:Investigations More fields visible Subcategories Note: These are mock screen shots. Final screens will be similar but not exactly the same Note: These are mock screen shots. Final screens will be similar but not exactly the same

IFM Case Management Review Capabilities • Assign and/or reassign cases to one or more investigators • View, search and filter on cases • Enter and view case priority, opportunity value and investigation type • Enter and view dated case notes for audit purposes and follow history • Enter estimated, actual and assessed recovery and autocalculate balance • Link cases, claims and external case system reference to a case • Track cases by detection source, case costs, and activity • Limit security access to a select group of individuals • Customize all drop-down lists to meet internal vernacular and workflows • Show Provider Score/Investigations in Claim Review summary • Ability to associate multiple providers to a single case 4.0 NEW 4.0 NEW

IFM 4.0Supporting Projects Add ‘Project’ as Standard menu option Project

IFM 4.0Link Analysis • Same functionality as previous IFM versions • Launchable from Review Claims or Review Provider • Provider ID automatically passed to Link Analysis application • Visualization Enhancements • High scoring providers quickly visible within a network • Provider scores visually available

IFM Link Analysis for Organized Fraud Use Cases: • Family relationships – Identifies providers writing prescriptions to themselves or the provider’s family members, also identifies providers treating groups of related Members • Office/Facility Address relationships – Identify providers that are sharing an address • Shared members among providers – Identify Providers sharing a substantial number of Members in common • Provider Practice relationships – Identify providers listed on common claims as a Provider and Billing Provider, also identifies providers sharing a common Federal Tax ID

IFM 4.0Search • Maintains Same functionality as previous IFM versions • Addition of a new simpler search capability • Text Search will be available in the Notes field for the Investigations module • Additional left pane search options to improve convenience to search using selected key fields.

Analytics

Insurance Fraud ManagerSelf-Adaptive • Find new and emerging fraud schemes by analyzing data patterns NOT rules • Model algorithms automatically adapt to different variables to detect new and emerging fraud schemes • SAMOATM (Self-Adaptive Modeling Optimization Algorithms) • Customers find 30% – 47% additional new cases above rules-based fraud detection • Eliminates the IT overhead staff to develop and maintain rules A

IFM 4.0Analytics • Facility Analytics visible in UI • 3 In-patient analytics • 4 Out-Patient analytics • Procedure Upcoding 4.0 NEW

IFM 4.0Analytics – Procedure Upcoding Provider Name: Benjamin Franklin Rank: 4 Specialty Declared: Chiropractic Specialty (Data Driven): Chiropractic Procedure Group Number: 1 Count of Procedures in Grp: 10 Amount Allowed in Group $227,343 Count of Claims in Group 413 Count of Total Claim by Provider 507

Facility Inpatient Claim Scoring Analytic Reason Codes

Facility Outpatient Claim Scoring Analytic Reason Codes

FICO® Insurance Fraud Manager User Group: San Diego, CA | May 7--8, 2014 Thank You Allyn Pon(858) 369-8487allynpon@fico.com

Transitioning to 4.0

IFM Transition Plans • Objective: Minimize customer impacts when transitioning to v4.0 • Configuration Packages will remain the same • Process Automation commands and structures will remain the same with additional ones added for facility operations • No anticipated major changes to the data spec across all claim types • No SSO changes • Upgrade Path Options • Fresh Install for v4.0 (Wellpoint’s current plan) • Upgrade in place for v3.3.3.1 to v4.0

IFM Technology Stack • Browser • IE 8 and above • Chrome 26.0 and above* • Middleware • WAS 8.5 (Java 6 support) • Tomcat 7* • LDAP • TDS 6.2 • Microsoft Active Directory • OpenLDAP2* • User • Windows 2008 • AIX 6.1 • Linux RHEL 6* • Scoring • Linux RHEL 6 • IRE/Link Analysis • Windows 2008 • Databases • Oracle 11g R2 • MongoDB v2.4 *New additions in 4.0

FICO Payment Integrity Solutions IFM 4.0 MEDICALClaim and Provider Scoring PHARMACY Claim and Pharmacy Scoring DENTAL: Provider Scoring FACILITY: Claim Scoring (inpatient and outpatient)

FICO Insurance Fraud Manager More Value and Benefits EasesDeployment Goes BeyondRules EnablesCompliance Lower TCO Lower TCO

Theme and Custom Colors To be used sparingly as accent colors. Theme Colors R 255 G 255 B 255 R 0 G 63 B 95 R 27 G 117 B 188 R 0 G 0 B 0 R 61 G 132 B 63 R 105 G 40 B 114 R 238 G 45 B 51 R 0 G 173 B 220 R 177 G 211 B 74 R 248 G 151 B 29 FICO blue FICO orange Custom Colors R 255 G 194 B 14 R 133 G 130 B 123 R 162 G 63 B 151 R 207 G 201 B 188 R 110 G 186 B 207 R 69 G 143 B 135 R 176 G 129 B 182 R 184 G 32 B 42 R 178 G 205 B 204

IFM 4.0 Sneak Preview