Healthcare & Insurance

FRAUD DETECTION IN HEALTHCARE INSURANCE

Code:

REACH-2020-THEMEDRIVEN-CEA_1

Domain:

Healthcare & Insurance

Description of the DVC THEME

In recent years, the health insurance sector has undergone major changes such as the generalization of Third Party Paying, the obligation of complementary professional services and the multiplication of dematerialized exchanges, which significantly increase the risk of fraud. At the same time, market concentration, policies to reduce public spending, and the strengthening of financial requirements for risk management, such as the regulations on mandatory financial solvency, are putting the margins of health insurance players under pressure. In this context, more and more organizations are looking for adapted strategies to fight more effectively against the financial burden of fraud.

Anti-fraud agencies conduct policies to fight fraud covering the whole cycle of life of suspicious files, from detection to final qualification after investigation. Insurance companies entrust these agencies to take care of the necessary actions with health professionals of suspected fraud. This can go up to their placing under surveillance or even their suspension from the national healthcare systems, in cases where their recurrent negligence or even when the agencies have proven their complicity in fraudulent actions.

Fraud can be detected using modern data analytics techniques, but this requires a strong collaboration between the stakeholders of this value chain: Insurance companies, healthcare professionals, antifraud agencies. But the main problem remains sharing of data among all these actors, as well as the specific know-how in every healthcare domain: medical, dentistry, eye care, pharmaceutics.

Sub-challenges composing this experiment:

This DVC THEME is composed by three main challenges:

    Expected global results:

    • To create a data value chain that allows antifraud agents to have the right data sources for early detection of fraudulent activities
    • To reduce the revenue losses of healthcare insurance companies caused by fraud, and allow them to keep their solvency as required by law
    • To protect healthcare professionals from repeated fraud perpetrators, by sending relevant alerts of potential fraud cases