Much ground to cover

RISKSA Magazine - - Medical -

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.

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