Tuesday, April 15, 2014

Data analysis findings in insurance fraud

It has been just over six months since we began providing on-line analytical services to one of our customers.  Their business focuses on insurance fraud detection, and through the use of Bimotics, exceptional cost-savings have been achieved and valuable lessons have been learned.  This project continues to be a success, with high customer satisfaction and glowing feedback from our customer. We have been able to demonstrate such great benefits in such a short time that considerations are being made to expand our reach into other types of insurance plans and other insurance providers.

For this project, Bimotics built a product for processing, storing and analyzing a huge amount of insurance claims data (millions of rows and data fields), allowing for auditors to find trends, patterns, outliers and further detailed analysis of the individual transactions. Basically, we allowed them to cull through an ocean of data and raise red flags, pinpointing where potential fraud was taking place.  We leveraged our proprietary Data Mart model which allowed us to analyze multiple insurance companies within a single data model.  This significantly smoothed the learning curve for auditors allowing them to focus on the analysis and not on the different data nuances of each company. Finally, our HIPAA compliant system (medical record integrity certification) allowed auditors to securely analyze millions of records within seconds.

The results so far have beat expectations:
  • Around $10 million in recognized savings after identifying the impact of claims for procedures that have limited medical value in unique scenarios.
  • 1,000s of claims were wrongly adjudicated.
  • Data Analysis can be used instead of on-site auditing because of greater efficiency with more results.
  • Less than 5% of identified providers in the sample represented more than 80% of the total amount of auditable claims. This analysis allowed our customer to focus on personal audits with the most potential impact, reducing time and high cost audit resources. In this scenario, the audits were performed on less than 1% of the total providers list and maximized results.

Lessons learned from this Customer:

  • The software-as-service business model made this project possible because capital investments were unnecessary, start up costs were low, and the customer could hit the ground running. The SaaS model plus consulting services allows business to start within days without the need for high initial cost and IT headaches.
  • Automating the data cleansing process after identifying each new need had the greatest impact on decreasing turnaround time. Millions of records were imported, standardized and analyze within minutes, not hours or days.
  • Collaboration is key, especially when the team of analysts are global or not in the same location. Secure web dashboards allow us to efficiently share and consistently communicate our findings.

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