COMBATING INSURANCE FRAUD TACKING FRAUD IN HEALTH, MOTOR UNDERWRITING AND APPLICATIONS
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1 COMBATING INSURANCE FRAUD TACKING FRAUD IN HEALTH, MOTOR UNDERWRITING AND APPLICATIONS
2 INTRODUCTION INSURANCE FRAUD ISN T GOING AWAY UK May 2014: Insurance fraud at record high, says ABI Italy Feb 2015: Insurance fraud, 17 in trouble Netherlands Sep 2014: Insurance Fraud costs each family 150 per year Greece Feb 2015: Garages in motor fraud Germany Feb 2015: Insurance fraud: agent caused 800,000 damages Belgium Oct 2014: 5 executives Ethias in insurance fraud
3 INTRODUCTION GLOBAL HEALTH INSURANCE FRAUD potential losses to healthcare fraud and corruption is billion across Europe estimates conservatively that $68 billion (3%) is fraud approximately 180 billion euros or 6 percent of global health care spending is lost to fraud each year
4 CRASH FOR CASH To stage or deliberately cause a road traffic collision solely for the purpose of financial gain.
5 CRASH FOR CASH 392m annual cost to industry 1 in 7 personal injury claims linked to Crash for Cash scams 1.7m average value of organised scam Source: Insurance Fraud Bureau
6 CRASH FOR CASH -_putting_the_brakes_on_fraud.pdf
7 CRASH FOR CASH Or. Approx. $48,000 Approx. 37,000
8 C o p y r ig ht , SAS I ns tit ut e I nc. Al l rig h ts r es er ve d. ORGANISED FRAUD Example of network
9 PROPERTY INSURANCE FRAUD TYPES THE NEW APPLE/SAMSUNG PRODUCT LAUNCH Look out for increases in Thefts Accidental damage claims Linked (by time) to launch of latest version With expectation that this is what you will replace them
10 HEALTHCARE FRAUD, WASTE & ABUSE Abuse Waste Fraud
11 HEALTHCARE PROVIDER FRAUD & ABUSE
12 C o p y r ig ht , SAS I ns tit ut e I nc. Al l rig h ts r es er ve d. Outpatient Rehabilitation Centers Air Transport ESRD Treatment Facilities Occupational Therapist Podiatrists Birthing Centers Imaging Centers Trauma Centers Ambulatory Surgical Centers Doctors Medical Equipment Suppliers Substance Abuse Facilities Dentists Hospitals Retail Health Outlet Mobile Health Urgent Care Facilities Pharmacies Chiropractors Dialy sis Centers Land Transport Optometrists Inf usion Centers Hospice Centers Psy chiatric Facilities Home Health Care Laboratories WHAT IS A PROVIDER? Substance Abuse Facilities Therapeutic Massage Therapists Phy sical Therapists Personal Care Assistants Inpatient Rehabilitation Centers Social Worker Rural Health Clinics Intermediate Care Center Pathology Laboratories
13 HEALTHCARE MEMBER FRAUD & ABUSE
14 HEALTHCARE WASTE
15 INTERNAL FRAUD Unfortunately happens in most insurers Examples Reopening claims Inventing claims on safe policies Part of organised criminal network Insider knowledge life/annuity account take over Place or groom insiders
16 INSURANCE FRAUD ANALYTICS THE SECOND LINE OF DEFENCE
17 Finding more suspicious cases & netw orks FRAUD ROADMAP ADVANTAGES OF THE HYBRID APPROACH We can take you on a journey Start with rules Move to hybrid analytics Network Peer Group Claimant History Single Claim
18 ANALYTICAL PLATFORM HIGH LEVEL FLOW Operational Sources Policies Claims/ invoices Investigations Data Management Ingest Cleansing Enrichment Quality analysis Entity resolution Social netw orks generation Fraud Detection Intelligence Repository Alert Generation Alert Management & Reporting GUI for selfadministration Investigations Potential Fraud Risk Suspicious alerts for Investigation Watch-lists Additional sources Data updates Intelligence updates Case Management Actions taken
19 Underwriting C o p y r ig ht , SAS I ns tit ut e I nc. Al l rig h ts r es er ve d. OPERATIONALISING ANALYTICS FUTURE TARGET MODEL Policy Application Claim at FNOL Triggered score SAS Analytics Hub Triggered score No Risk No Risk Fraud Risk Initial Fraud Triage Fraud Suspicions Automatic continual scoring Fraud Suspicions Fraud Risk Initial Fraud Triage No Risk No Risk Claims Full Investigation No Action Required Confirmed Fraud Confirmed Fraud No Action Required Policy Acceptance Reject Action Updates Reject Action Claim Acceptance
20 Fraud now is the time for action Todays methods are not enough Business analytics should be an integral part of your strategy a second line of defence Detection and prevention C o p y r ig ht , SAS I ns tit ut e I nc. Al l rig h ts r es er ve d.
21 QUESTIONS? DAVID HARTLEY DIRECTOR OF INSURANCE FRAUD SOLUTIONS w ww.sas.com
Global Trends in Insurance Fraud : Next Generation Network Analytics
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important
Medical EPO Plan Schedule of Benefits (Effective January 01, 2019) Howard County General Hospital/TCAS Employees and Eligible Dependents
Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Hopkins Affiliated Facility Network (facility charges only) EHP Network Provider Individual $500 $500 Family $1000 $1000 Individual $3000 (combined
Anthem Blue Cross Your Plan: Classic HMO 20/40/250 Admit /125 OP ($5/$15/$30/$50/30%) Your Network: California Care HMO
Anthem Blue Cross Your Plan: Classic HMO 20/40/250 Admit /125 OP ($5/$15/$30/$50/30%) Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myiuhealthplans.com or by calling 1.866.895.5975. Important
VA Aetna Whole Health Silver $10 Copay NA CSR $0
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthreformplansbc.com or by calling 1-855-586-6960.
Chapter 5: Billing on the CMS 1500 Claim Form
Chapter 5: Billing on the CMS 1500 Claim Form Introduction The CMS 1500 claim form is used to bill for non facility services, including professional services, freestanding surgery centers, transportation,
Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP (Essential Formulary $10/$25/$45/30%) Your Network: California Care HMO
Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP (Essential Formulary $10/$25/$45/30%) Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to
Anthem Blue Cross Your Plan: Custom Value Deductible HMO $100 30/40/10% Your Network: Select HMO
Anthem Blue Cross Your Plan: Custom Value Deductible HMO $100 30/40/10% Your : Select HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This