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A preemptive approach to detecting fraud and abuse

With the industry losing billions each year, proactive solutions are vital

The healthcare industry loses tens of billions of dollars each year to fraud alone, with current in-market tools detecting only a subset of suspicious claims. Using AI and behavioral patterning, Mastercard sets out to stop claims-related fraud before it can impact?the payer.

Fraud, waste, and abuse (FWA) have a massive financial impact on the industry:


Fraud, waste, and abuse cost payers an estimated $240 billion annually1


Of the $389 billion in Medicare fee-for-service spending in 2018, an estimated $32 billion came from improper payments2

Pinpoint fraud before claims are paid

Most problematic healthcare claims are caught post-adjudication, leading to overpayments. Using rapidly adapting, self-learning artificial intelligence, capable of analyzing nearly 100 billion transactions annually, payers can identify and investigate suspicious claims prior to settling with providers. The solution also leads to fewer false positives, which means heightened efficiency with less reliance on human capital.

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Healthcare Solutions: Fraud, Waste, and Abuse whitepaper

Discover how Mastercard’s AI technology can help detect suspicious claims, keeping costs down and profits up.

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1. Low estimates of fraud, abuse, and overtreatment in 2011. Donald M. Berwick and Andrew D. Hackbarth, “Eliminating Waste in US Health Care,” Journal of American Medical Association, 307, no. 14, April 11, 2012

2. U.S. Government Accountability Office, Medicare and Medicaid, Appendix II: Fiscal year 2018 Medicare Improper Payment Data, March 2019.