Page 266 - Ebook health insurance IC27

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Q8. How fraud can be combated through Technology and Process Interface.
Ans. Frauds can be combated through various Technology and Process Interface steps.

They are as follows :
(i) Ease of Data Transfer - The claim process should be easy and user friendly for

all stake holders . If complete claims data is not available, then the system will not
be able to display fraud triggers/alerts effectively.
(ii) Comprehensive Claims Information - To ensure robust fraud management and
pick up relevant fraud alerts, the system should have comprehensive data fields.
Importantly to avoid poor data quality, fraud management systems must have
effective validations.
(iii) Ability to Detect Fraud Effectively - In order to successfully prevent fraud,
logical methodology should be used. The system should be able to identify and
detect frauds. The various frauds which the system should be able to identify are:
(a) Adverse claim ratio for a agent/partner/group

(b) Adverse claim ratio for a given profile/occupation/income group

(c) Higher LOS (length of stay) for a given ailment

(d) Higher treatment cost for a given ailment.

(iv) Extract Data Output in a Desirable or Actionable Format - All the data
captured should be available to the management in a desirable format for easy
decision making and regulatory reporting.

(v) RAG Analysis - The entities that provide business are analyzed on periodic basis
and the worst performers in terms of claims (related to Hospitals, Agents, Diagnostic
Centres etc) are assigned RED ratings, mediocre performances are given Amber
and best performers are assigned Green ratings, through statistical analysis and
segment classification mechanisms.

(vi) Propensity Modeling - This aims at identifying the potential fraudsters based on

270 Guide for Health Insurance