Page 255 - Ebook health insurance IC27

Sashi Publications

 Adverse claim ratio for a given profile/occupation/income group
 Higher length of stay for a given ailment
 Higher treatment cost for a given ailment

4. Extract data output in a desirable or actionable format
 Data must be presented in a desirable format for making the decision making easy

5. Rag analysis
 Assign ratings tools hospitals/agents/diagnostic centres/doctors
 Take action against service providers whose rating are bad
 Encourage service providers whose ratings are good

6. Propensity modeling
 Identify potential fraudsters based on past experience
 Check the trend of claim
 Check policies on a sample basis for fraud regularly

7. Underwriting/claims rules engine
 Build strong underwriting rules and claims rules
 It should have built-in measures to detect fraud
 Expert claim managers should analyse high claim cases
 Use business process transformation tools to enable insurers to make quick changes

in the rules

8. Fraud investigations
 Appoint investigators if fraud is suspected
 Separate agency may be appointed who may have a specialisation
 Special team may be created within the company

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