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WellPoint's Patrick McIntyre on anti-fraud analytics partnerships


FierceHealthPayer: Anti-Fraud: Some vendors have been described as "good dates but terrible spouses." How can payers avoid contracting with companies whose service levels drop dramatically once a contract is signed?

Patrick McIntyre: Thorough reference checks are key. Don't just interview potential partners; dig deep to find out if they can and have delivered on what they sell.

For a fraud detection vendor we selected, we met with a couple of their existing customers and in one case spent an entire day on site with them. Without the vendor present, we asked questions about what worked and what didn't. We saw and experienced the end product.

Also, my goal with contracts is to finalize everything we could possibly want in the contract before signing, and then put the document in a drawer and never have to bring it out again.

But if you must do that, it's important to be absolutely clear about what the intent of the parties are. For any analytics vendor, you need a robust service level agreement in place with clear performance metrics you can track and monitor regularly. This keeps conversations with vendors objective rather than subjective. We include performance guarantees or penalties for failure to meet objectives wherever possible.

FHPAF: What's the status of anti-fraud predictive analytics: Are they a dream for the future, or are they available now?

McIntyre: This is still a developing area, though we're getting better at it as an industry. There are predictive analytic methodologies in place today, but many are based on historical patterns. With the proliferation of big data and the ability to get more external information through social media and text mining, I think we'll get better at predictive analytics.

Meanwhile, I tell my folks that web research is critical to fraud detection. It's important to learn what fraud practices are implemented nationwide and what the new fraud schemes are. Some move faster than we can react to, so staying current on trends is critical. Criminals move on to the next fraud practice or the next fraud victim. In either case, you've got to stay on top of your game.

FHPAF: Do you have any other smart shopping or "let-the-buyer-beware" tips not covered in the above questions?

McIntyre: Do your homework on the front end to find organizations with whom you can work closely and truly partner. Remember to look for partnerships; if you settle for a vendor relationship, you're probably in the wrong starting spot.

Look for organizations that want to grow with you and implement what you've learned together in the analytic capabilities you use and build.

Find partners you can work with to improve not only what you do but their products as well. Then use objective criteria to track and monitor partner performance. That's the winning combination for success.

Editor's Note: This interview has been edited and condensed for clarity.