A method of personalizing, individualizing, and automating the management of healthcare fraud-waste-abuse to unique individual healthcare providers, comprising:
- collecting and aggregating with a processor and an algorithm executed by the processor that combines incoming streams of electronic data records of healthcare payment request claim data originated by a variety of healthcare providers with a correlated non-claim based utilization data, actual clinical data, and pharmacy claim or transaction data, and that stores such a data correlation and combination as cleaned and enriched data records in a computer memory storage device;
- initializing a continual and individual tracking of distinct behaviors of the variety of healthcare providers with the processor and an algorithm executed by the processor that creates and adapts a unique and independent smart agent profile assigned to and maintained in the computer memory storage device for each and every one of the variety of healthcare providers;
- continually comparing with the processor and an algorithm executed by the processor that retrieves a corresponding unique and independent smart agent profile, and that matches such to an instant incoming electronic data record of healthcare payment request claim data, and that computes therefrom any new deviation of behavior;
- simultaneously classifying said instant incoming electronic data record of healthcare payment request claim data with the processor and an algorithm executed by the processor that applies a fraud-waste-abuse criteria and a predictive model trained by supervised and unsupervised learning technologies;
- classifying each said new deviation of behavior with the processor and an algorithm that applies a unique individual behavior criteria based on a comparison of an individual past behaviors extracted and recorded in their unique healthcare provider profile and an instant behavior evident in the instant incoming healthcare payment request claim stored in the computer memory storage device;
- issuing a decision with the processor and an algorithm that estimates an instant healthcare payment request claim as fraudulent-wasteful-abusive based on a combination of the classifying each said new deviation of behavior and any predictions from the simultaneously classifying said instant incoming electronic data record of healthcare payment request claim data;
- and
- directing the above to any subsequently received incoming healthcare payment request claims, and repeating the above if an instant payment request claim was estimated as not being non-fraudulent-wasteful-abusive.