Research Brief: From Prediction to Explainable Provider Behavior Profiles
by Yubin Park, Co-Founder / CTO
White Paper · Research Brief #2
See how human-readable billing profiles can turn an unexplained change into a focused investigation or a productive provider conversation.
Read the Full White Paper
Claims data can tell you when a provider's billing changes. The harder—and more useful—question is why.
Many analytics tools produce a risk score or forecast. They can say that a provider looks different from expectations, but they often leave the reviewer to figure out what actually happened. Did billing volume jump? Did the provider add a new service? Did the mix of procedures change? Is the shift visible across Medicare, or only within one health plan's members?
Our approach makes those changes visible in plain language. Instead of stopping at an alert, Falcon shows the billing facts behind it:
- How much the provider's billing grew or declined
- Which services and procedure families drove the change
- Which codes appeared for the first time
- Whether the same pattern appears in broader Medicare activity
- What questions an investigator or provider-relations team should ask next
An alert people can understand
An unexplained billing change should not be a black-box accusation. It should be the start of a clear, evidence-based review.
Falcon's profiles let an analyst see that a provider's billing increased, identify the services responsible, and compare the pattern with the provider's broader history. That gives the reviewer a concrete place to begin instead of another score to decode.
We evaluated this approach across eight quarters of Medicare Carrier and DME activity covering 1.22 million providers. Certain large billing changes had meaningful relationships with later Medicare enrollment revocations and HHS OIG exclusions. These results do not prove that every unusual change is fraud. They show that understandable billing patterns can help teams build a more focused and useful review queue.
Useful beyond FWA investigations
The same profile can support a very different conversation: “We noticed your billing pattern changed. Can you help us understand why?”
A new service line, a coding change, a shift in patient mix, or a change in business operations may have a reasonable explanation. By showing exactly what changed, healthcare organizations can have a productive discussion with the provider rather than beginning with an opaque risk score or an accusation.
That makes explainable provider profiles useful for program integrity, payment integrity, network management, provider education, and ongoing billing oversight.
The profile guides human review; it does not determine intent or declare fraud on its own.
Read the full white paper for the complete methodology and validation. To discuss how explainable provider profiles could support your organization, get in touch.