Much ground to cover
According to Smith, the big scheme’s biggest challenge is not finding irregularities, but finding the available manual component to follow up. “What we have had to do alongside the technology aspect, is expand our human capacity so that we are able to investigate the red flags. This is definitely a component where a lot of other companies often fail – most large schemes have the ability to call out the anomalies on their systems, but then they don’t have the capacity to effectively investigate,” Smith says. “The reality is that when you are dealing with fraud, you can only successfully manage that risk if you are able to investigate. We have also spent a lot of time and energy on building the analytical tools and models to assist our investigators in that process. One of the latest tools that Smith boasts of, is the fraud risk rating system that his department has unveiled. “Effectively it assigns a fraud risk rating to healthcare professionals claiming from us on a continuous basis. Each claim is now being viewed on an individual basis and simultaneously being compared to the claims coming in from this professional’s peers and measured against a number of other criteria that helps us to identify outliers.” Smith adds that the medical insurance sector is the most complex of the industries that Discovery deals in, since the number of permutations are seemingly endless. “The majority of fraud that one could expect against a medical aid scheme, would be on the claims side. But if you look at the various branches in the medical profession, each one of these professionals’ claims need to be measured against different sets of criteria.