Fighting fraud in the supplementary health sector is a constant challenge for medical account managers and analysts. Fraud has a significant impact on costs and the quality of services provided.
The types of fraud in the sector vary, and include everything from the manipulation of medical bills and overcharging to the falsification of medical records.
To mitigate these risks, various strategies and practical actions have been implemented by health insurance companies around the world.
In this article we present some of these actions and highlight successful cases that demonstrate the effectiveness of these measures. Read on to the end!
Check out the main practical actions to reduce fraud
1. implementation of data analysis technologies
One of the most effective strategies for combating fraud is the use of data analysis technologies. Predictive analytics and big data tools can identify suspicious patterns and anomalies in large volumes of medical transaction data.
Case Study: UnitedHealth Group
UnitedHealth Group, one of the largest healthcare companies in the US, is using predictive analytics to detect fraud. The company has implemented a system that analyzes millions of transactions to identify unusual behavior patterns. This has helped to significantly reduce fraud, saving billions of dollars.
2. Medical Accounts Audits
Audits of medical accounts are essential for identifying undue charges and services not provided. The largest healthcare operators in Brazil use the SAUDI systemwhich automates medical auditing, care cost management, population and individual health.
Case Study: Unimed
In Brazil, more than 50 Unimed units use the SAUDI system for the audit that reviews all medical bills with the support of advanced IT tools. This has enabled the company to identify and correct fraud, increasing confidence in healthcare management.
3. Employee Education and Training
Educating and training employees to spot signs of fraud is crucial. When employees are well informed about common forms of fraud, they can act as the first line of defense.
Case Study: Blue Cross Blue Shield
Blue Cross Blue Shield has developed training programs for its employees and service providers, focusing on ethics and fraud recognition. This has resulted in faster and more effective fraud detection and the promotion of a culture of integrity.
4. Collaboration with Security Forces and Regulatory Entities
Working together with police authorities and regulatory bodies can improve detection and action against fraud. This collaboration can include sharing information and participating in joint investigations.
Case Study: Kaiser Permanente
Kaiser Permanente actively collaborates with government agencies in the United States to combat health care fraud. This partnership has led to the identification and dismantling of criminal networks involved in insurance fraud.
5. Use of Artificial Intelligence (AI)
Artificial intelligence can be used to analyze data in real time, identifying atypical behaviors that may indicate fraud. In addition, AI can help automate auditing and verification processes.
Case Study: Discovery Health
In South Africa, Discovery Health uses AI to monitor suspicious transactions and activities. This technology has enabled the company to proactively detect fraud, increasing efficiency and reducing the costs associated with fraud.
6. Creation of Whistleblowing Channels
Providing secure channels for employees, service providers and beneficiaries to report fraud can increase detection and prevention. It is important that these channels guarantee anonymity and protection against retaliation.
Case Study: Cigna
Cigna implemented an anonymous reporting system, which encouraged employees to report suspicious activity without fear of reprisals. This resulted in a significant increase in fraud detection and the protection of company resources.
7. Review of contracts with service providers
Regularly reviewing and updating contracts with service providers can help prevent fraud. Contracts should include clauses that encourage transparency and accountability.
Case Study: SulAmérica
SulAmérica, one of Brazil's largest insurers, has implemented an ongoing review of contracts and processes with service providers. This helped identify areas of vulnerability and strengthen control mechanisms.
Discover the secret of dozens of Brazilian health operators
Reducing fraud in supplementary health management requires a multifaceted approach that combines technology, training and collaboration. The success stories highlighted demonstrate that by implementing the ideal solution, combined with effective and innovative practices, it is possible to minimize the impact of fraud and improve the quality of healthcare services.
By adopting the SAUDI systemBy using the system used by dozens of healthcare operators in Brazil, managers not only protect their financial resources, but also reinforce the trust of beneficiaries and service providers in the supplementary healthcare system.
Get in touch now with an expert from the team SAUDI and request a free no-obligation demo! ; )
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