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The Healthcare Claims Leakage Problem

Claims Leakage, covering errors, over-servicing, tariff up-coding, and fraud, exists in the Australian private health insurance industry. While reliable statistics are not available in Australia, estimates internationally put this at between 3%¹ and 10%² of claims.

Leading-edge Healthcare Claims Surveillance and Audit

CMC-HIBIS is a leading edge surveillance and audit solution for health care claims, identifying all forms of leakage. The solution is underpinned by multi-disciplinary supporting services covering claims adjudication and auditing, business rule development, healthcare coding, and software engineering.

The solution will help you with:

• Identifying and then recovering and/or preventing leakage
• Meeting compliance responsibilities
• Raising transparency, leading to improved quality of care
• Improved provider contracting and member product development
• Providing general business intelligence in health claiming

CMC-HIBIS has been developed as part of a government, education and industry collaboration in the Capital Markets CRC. The CMCRC has, in conjunction with industry partner SMARTS Group, successfully developed and commercialised surveillance solutions that are used by regulators, exchanges and brokers in over 40 countries. The solutions allow these parties to conduct real-time surveillance to identify practices that undermine market integrity such as insider trading, market manipulation, and broker-client conflict. In March 2010, this solution was selected by the Australian Securities and Investments Commission (ASIC) to provide real time surveillance of Australia’s equities markets.

Though CMC-HIBIS is specific to the health insurance domain, it has benefitted from key aspects of this earlier development including data management, data-mining and data visualisation skills.

References

1. “The U.S. spends more than $2 trillion on healthcare annually. At least 3 percent of that spending – or $68 billion – is lost to fraud each year.” Source: National Health Care Anti-Fraud Association, 2008.

2. “Statistics show that because of the pervasiveness of health care fraud, 10 cents of every dollar spent on health care goes toward paying for fraudulent health care claims.” Source: Legal Information Institute Cornell University.