Embed Size (px)
DESCRIPTION
Blaze Advisor Business Rules Management System (BRMS). Blaze Advisor Integration with IFM. Blaze Advisor BRMS provides the capability for non-technical resources to configure and deploy: - PowerPoint PPT Presentation
Citation preview
© 2014 Fair Isaac Corporation. Confidential.1
Blaze Advisor Business Rules Management System (BRMS)
2 © 2014 Fair Isaac Corporation. Confidential.
Blaze AdvisorIntegration with IFM
► Blaze Advisor BRMS provides the capability for non-technical resources to configure and deploy: ►Fraud, Waste and Abuse rules on data elements included in the data feeds
to/from Insurance Fraud Manager (Professional, Facility) ►Capability to implement blues card rules prior to payment ►Workflow management rules to more effectively manage the review of
individual claims within Insurance Fraud Manager►Rules which manage systemic issues identified by IFM or other means
► Blaze is preconfigured to accept your data►Blaze uses existing IFM feeds. No new data feeds required from IT.
► Blaze can be expanded to accept ANY data source ►Clients can choose to integrate any data source to make a claim payment
decision
3 © 2014 Fair Isaac Corporation. Confidential.
Current State Implementation
IFM Data FeedsClient Claim
System
Decision(Pend, Deny, Pay)
Blaze AdvisorIntegration with IFM
IFM User Interface
IFMScoring Engine
ŸŸŸ
Dynamic ProfileProviders
Members
Claims
Dental
Pharmacy
Ratio of X- rays to exams
$ billed vs. peers
Procedure mix vs. peers
Max single- day activity
Profile Variable N
DerivePowerfulVariables
Scores and Reasons
PredictiveModels
4 © 2014 Fair Isaac Corporation. Confidential.
IFM Data FeedsClient Claim
System
Decision (Pend, Deny, etc)
Blaze AdvisorIntegration with IFM
IFM User Interface
IFMScoring Engine
ŸŸŸ
Dynamic ProfileProviders
Members
Claims
Dental
Pharmacy
Ratio of X- rays to exams
$ billed vs. peers
Procedure mix vs. peers
Max single- day activity
Profile Variable N
DerivePowerfulVariables
Scores and Reasons
PredictiveModels
Blaze is pre-configured to ‘plug and play’ with IFM, using IFM data feeds and advice files
Rules,Strategies, Models
Blaze Advisor Rule Service(s) How Blaze
Advisor Works
Blaze Advisor Rule Service(s) How Blaze
Advisor Works
Blaze Advisor Rule Service(s)
The addition of Blaze Advisor provides a platform to close FW&A gaps through business rules
5 © 2014 Fair Isaac Corporation. Confidential.
IFM Data FeedsClient Claim
System
Advice File(Pend, Deny, Pay)
Blaze AdvisorIntegration with IFM
IFM User Interface
IFMScoring Engine
ŸŸŸ
Dynamic ProfileProviders
Members
Claims
Dental
Pharmacy
Ratio of X- rays to exams
$ billed vs. peers
Procedure mix vs. peers
Max single- day activity
Profile Variable N
DerivePowerfulVariables
Scores and Reasons
PredictiveModels
Blaze Advisor’s Rule Management interface allows non-technical users to deploy rules
Rules,Strategies, Models
Blaze Advisor Rule Service(s) How Blaze
Advisor Works
Blaze Advisor Rule Service(s) How Blaze
Advisor Works
Blaze Advisor Rule Service(s)
Fraud RulesWaste RulesAbuse RulesPolicy Gap Rules
Analyst Rule ControlDefine
Decision (Pend, Deny, etc)
6 © 2014 Fair Isaac Corporation. Confidential.
IFM Data FeedsClient Claim
System
Advice File(Pend, Deny, Pay)
Blaze AdvisorIntegration with IFM
IFM User Interface
IFMScoring Engine
ŸŸŸ
Dynamic ProfileProviders
Members
Claims
Dental
Pharmacy
Ratio of X- rays to exams
$ billed vs. peers
Procedure mix vs. peers
Max single- day activity
Profile Variable N
DerivePowerfulVariables
Scores and Reasons
PredictiveModels
Additional data sources can be leveraged to analyze and decision claims
Rules,Strategies, Models
Blaze Advisor Rule Service(s) How Blaze
Advisor Works
Blaze Advisor Rule Service(s) How Blaze
Advisor Works
Blaze Advisor Rule Service(s)
Fraud RulesWaste RulesAbuse RulesPolicy Gap Rules
Analyst Rule ControlDefine
Other Data Sources
Decision (Pend, Deny, etc)
7 © 2014 Fair Isaac Corporation. Confidential.
Learnings from both IFM and Non-IFM findings can be deployed via Blaze
IFM Data FeedsClient Claim
System
Rules,Strategies, Models
IFM User Interface
Fraud RulesWaste RulesAbuse RulesPolicy Gap Rules
Analyst Rule ControlDefine
Blaze Advisor Rule Service(s) How Blaze
Advisor Works
Blaze Advisor Rule Service(s) How Blaze
Advisor Works
Blaze Advisor Rule Service(s)
IFMScoring Engine
ŸŸŸ
Dynamic ProfileProviders
Members
Claims
Dental
Pharmacy
Ratio of X- rays to exams
$ billed vs. peers
Procedure mix vs. peers
Max single- day activity
Profile Variable N
DerivePowerfulVariables
Scores and Reasons
PredictiveModels
Advice File(Pend, Deny, Pay) Deploy
Adaptive Loop
Non- IFM findings
IFM findings
Blaze AdvisorIntegration with IFM
Other Data Sources
Decision (Pend, Deny, etc)
8 © 2014 Fair Isaac Corporation. Confidential.
Rule Examples:► Blues Card Edits ► High Unit Rules► Social Security Death Master► Provider Black Lists► Always Approve► Always Deny► Derived data based on complex calculations/formulas.
Blaze AdvisorIntegration with IFM
