Category: Business & Marketing

How Tranzform Security Can Help You Reduce Insurance Fraud

Health care spending accounts for 17.8% of GDP in the United States. In Canada total health care spending is reported to be 11% of GDP.

The dispensing of health care uniquely depends of a healthy relationship between health care plan administrators and diagnosing physicians prescribing access to the benefits and services of the plan. In some circumstances, other types of insurance (i.e., property and casualty and workplace insurance) draw on these same resources from dispensing medical benefits and services of their plans.

Diagnosing physicians are expected to diagnosis illnesses and injuries accurately, and to prescribe only necessary services. These physicians, as well as other regulated professionals, are guided by controls to assure the billing integrity of the system. When plan administrators have deception concerns beyond billing integrity issues, they may make referrals for investigation. Wrong-doing can end up at civil and/or criminal proceedings.

Physicians are the gatekeepers for access to the plans. Their influence and the importance of their cooperation can not be overstated. No group is better positioned to offer advice on reducing waste, misuse and abuse to a wide range of health care products and services (i.e., pharmaceuticals, hospitalization, rehabilitation, durable medical equipment, home care, physio therapy etc).

Controlling waste, misuse, and abuse of health care resources is foremost a people challenge. Without trust and cooperation between plan administrators and diagnosing physicians to control waste, misuse and abuse, plans will continue to be exposed to avoidable financial harms. Yet, it is still inevitable that some will cheat the system when tempted, and from a range of environmental pressures. The science is in how you treat mostly honest people. Believe us, their contemporaries are watching. 

Why Work with Us?

We think of insurance plans as complex systems. We draw on two bodies of expertise: i) Behavioral Insights teams to control diagnosing and other practitioner billing incidents when people are tempted to do bad things, ii) Data Science teams early detection of high risk hot spots and patterns, and iii) Situational Crime Prevention Science teams to detect, prevent and reduce predatory criminal fraud; and 

Applying Behavioral Insights to Temptations

Our behavioral insights team operates with specific beliefs about trusted diagnosing and services partners: 

  • With the exception of a few, most people are moral and who, from time to time, do bad things when tempted;
  • Early detection and correction is critical. Once the Rubicon has been crossed from billing integrity to cheating a little bit, it becomes easier to rationalize escalating bad behavior, and no-more-so than in environments which offer excuses;
  • Diagnosing physicians are the gatekeepers. They are the eyes and ears of the system, offering boundless opportunity to minimize waste, misuse and abuse of the plan (i.e., beneficiary entitlement, medical identity fraud, pharmaceuticals, hospitalization, rehabilitation, durable medical products, home care etc.);
  • There is no cooperation in preserving the system without mutual respect and trust between plan administrators and trusted billing providers, and
  • The language used and actions taken against mostly honest people in the trusted billing ecosystem are not the same as for predatory fraud attacks by people without moral conscience.

From the science on “tit for tat” (reciprocal altruism) it is predictable that most physicians are willing to  cooperate with plan administrators in reducing losses from waste, misuse and abuse. But they will expect cooperation in return. Building and sustaining trust and cooperation is complex. It is dynamic – it never ends.

A Problem-solving to Fraud Controls for Countering Predators

Predatory fraud attacks from outside the system, and by the few morally bankrupt inside the System, is a problem of a different nature. These are people without moral conscience.

We apply the problem-solving skills and lessons learned from situational crime prevention to identify and reduce fraud attacks.

We teach the insurance sector how to develop Stakeholder partnerships, and how to engage teams of expertise in identifying and attacking the root causes of potential fraud trends, hot spots, trends and patterns.

We introduce our clients to a Situational Health Care Fraud Prevention Matrix  designed from years of research and experience with health care fraud controls. Using this model, enforcement is applied as one of multiple intervention tools for reducing fraud problems.

Design Thinking: a foundation for Business Innovation

“Innovate or Die” is a popular expression among thought leaders to describe the economic and cultural climate we now do business in.  Technology’s impact on people and business continues to evolve the way we communicate, work and live at a disruptive pace.  Businesses need to respond by innovating their business models and experimenting with new methods of doing business.

Innovation today requires a creative way of thinking, Design Thinking.  We need a foundation to experiment with new ideas that apply emerging tools and models to existing methods of doing business.  Design thinking is not new, though its popularity has grown in the digital age as a practical methodology for leveraging emerging technologies and modernizing business models.

Applying design thinking to innovation adopts a solution-focused mindset that combines empathy, rationality and creative insights into business, technology and people.  This is important because integrating emerging technologies is simply not enough to achieve competitive advantage and sustainability.  We must not only innovate the tools we use, but the methods in which we use them.  We must understand that current business cultures and practices can be a barrier to innovation.  We need to recognize that consumers are more tech-savvy and social than ever before.  We need to enable people as much as we enable the business.

Design Thinking model illustrating the innovation zones and relationships between business, people and technology:

Design Thinking Model

Popular words of caution, “It’s not about the technology…” reminds us to be empathetic to be innovative.  Empathetic to who? People. The people that work for your business and the people that buy your products and services.  When we understand how culture is evolving inside and outside the business, when we understand the behaviors of consumers, we will be better equipped to innovate.

The challenge today is to break free from our comfort zone to unlearn and rethink how we do business and foster new competitive advantage.  Our world is in a state of great change, we need to take a step back and be willing to open our mindsets.  I believe the methodologies of Design Thinking can be applied to business innovation and guide leaders in the right direction.  There is as much opportunity as there is threats in the digital age and businesses will either “Innovate or die.”

http://www.youtube.com/watch?v=6axgrZUrqH8

Part 2 – Design Thinking: methods to business innovation

References:

Organizational Design from the Industrial Age to the Digital Age

As the Information Age continues to evolve at a rapid rate, businesses are finding it challenging to compete in their marketplace.  New technologies, global markets, demanding customers, disengaged employees and aggressive competitors are placing unprecedented pressure on many companies, who must now rethink the way they do business.  In order to be successful within the current economy, businesses must ensure that the collective efforts of their workforce are aligned with their strategies, goals and principles.  More importantly, companies must transform their business into a Digital Firm (Industrial Economy → Digital Economy).  Where business processes, information, technology and relationships with customers, suppliers and employees are digitally enabled and key corporate assets are managed through digital means.

4 Fundamental Elements for Organization Design

  • Empowers the capabilities of your people.
  • Enhance collaboration, communication and management amongst workforce.
  • Develop efficient digital business systems and programs.
  • Design an effective, agile and sustainable organizational structure.
  • Establish a supportive work culture.

Organization Design transforms complex enterprise ecosystems into flexible, agile and sustainable organizations that can respond and pivot to external and internal developments and achieve success.

Engaging Content. Whether to Embed or Link?

Showing a collection of PowerPoint slides pulled from an OpenText Content Server was the subject of a recent post. At that time, I used presentations from our Content World Users’ conference of a year ago to show how a collection of related materials from a secure enterprise repository could be embedded in the post using OpenText Widget Services (OTWS).Last week was the latest Content World 2011 conference, which provided me with a rich set of new materials to show Widget Services’ capabilities. Note: All of these presentations are already available individually from OpenText Online Communities (login required)Full screen collection – In my previous post the collection was embedded within the post. You could expand it if you chose. But there are times when you want to show full-screen off-the-bat. So here are a collection of presentations related to our eDOCS offering:

  • Just click on this link to view the collection
  • Select one, get details, view it in a player, download it, or get the embed code to use elsewhere.

Collection embedded – Frankly I find the full screen version above more compelling, but there are times when you need to embed in context, much as you might embed a video from OpenText Video Services. So here is the same collection embedded here to illustrate that: A single presentation in a player – In contrast, here is a single presentation, this time about Widget Services, opened in a viewer when you click this link.

What’s the difference between Business Continuity (BC) and Disaster Recovery (DR)?

What’s the difference between Business Continuity (BC) and Disaster Recovery (DR)? This is a question I have had to answer multiple times. It is a very good question and the answer is not simple! So, as a good lazy ‘techy’, I tried to find the answer on the web. That way, when I am asked, all I would have to do is send a link.

I have used this approach multiple times for other questions I have received. It is convenient and a great way to avoid re-typing an answer. However, this time, I was not very successful in my quest to find an answer. I searched the web, multiple times, for hours without finding the perfect “pre-written answer” I was looking for. So I decided to stop being lazy and write it myself.

Now, if you are like me, and you’ve been looking for an answer to this question, feel free to use this one.

So, let’s start with a few definitions from the Business Continuity Institute (BCI) Glossary:

Disaster Recovery (DR): “The strategies and plans for recovering and restoring the organizations technological infrastructure and capabilities after a serious interruption. Editor’s Note: DR is now normally only used in reference to an organization’s IT and telecommunications recovery.

Business Continuity (BC): “The strategic and tactical capability of the organization to plan for and respond to incidents and business disruptions in order to continue business operations at an acceptable predefined level.”

First, I’d like to say that I have a slightly different view of DR than BCI. Now, who am I to disagree with what BCI is saying? Well, bear with me a little longer and you will see how my interpretation of DR might help people understand the differences between DR and BC better. So here’s my definition:DR is the strategies and plans for recovering and restoring the organizations (scratch technological) infrastructures and capabilities after an interruption (regardless of the severity).

Unlike the BCI, I don’t make a distinction between the technological infrastructure and the rest of the infrastructures (the buildings for example) and nor I do differentiate between the types of interruptions. In my opinion, either a system is down or a building is burnt or flooded, both should be considered a disaster and therefore both require a disaster recovery plan.

Therefore DR is the action of fixing a failing, degraded or completely damaged infrastructure. For example, the 2nd floor of a building was on fire; the fire is now out so the initial crisis is over. Now the damage caused by fire must be dealt with; there is water and smoke on the 2nd floor, the 3rd floor has damages caused by smoke and the 1st floor has water damage. The cleanup, replacement of furniture, repair of the building and its structure, painting, plastering, etc. are all part of the disaster recovery plan.

What is Business Continuity then? Business Continuity is how you continue to maintain critical business functions during that crisis. Back to the example, when the fire started, the alarm went off and people were evacuated from the building. Let say you had a Call Center on the 2nd floor and this just happens to be a critical area of your business. How would you continue to answer calls while people are being evacuated? How would you answer calls while the building is being inspected, repaired or rebuilt? Keeping the business running during this time is what I call Business Continuity.

The same approach can be taken with a system crash or when the performance of a system has degraded to the point that it has impacted business operations. So fixing the system is DR and the action of keeping the business operations running without the system being available is BC.

In conclusion, BC is all about being proactive and sustaining critical business functions whatever it takes whereas DR is the process of dealing with the aftermath and ensuring the infrastructure (system, building, etc.) is restored to the pre-interruption state.

Cloud Computing Defined

Welcome to the first installment of what will be an on-going series on Cloud Computing.  Everyone in the industry is talking about it and the media is awash with hype.  I’ll be taking a different approach by trying to bring some clarity and reason to help you make informed decisions in this area.

The place to start is with a definition of the term.  There are a wide variety of sources that attempt to define Cloud Computing, many with subtly different nuances, and often including benefits (e.g. flexibility, agility) that are potential outcomes from going Cloud, but certainly don’t belong as part of its definition.

I prefer the U. S. Department of Commerce National Institute of Standards and Technology (NIST) draft definition which is well-considered, well-written and carries the weight of a standards body behind it.  Their definition sets out five essential characteristics:

  1. On-demand self-service: This means that a service consumer can add or delete computing resources without needing someone working for the service provider to take some action to enable it.
  2. Broad network access: Note that the NIST definition does not specify that the network is the Internet (as some other definitions do).  This is necessary to allow for private clouds.  NIST goes on to say that cloud services use standard mechanisms to promote use by a wide variety of client devices.  It’s not clear to me that this should be a full-fledged requirement, but is certainly in keeping with the spirit of the cloud concept.  Once could imagine a cloud that uses custom protocols agreed to by a closed group of consumers, but perhaps the word “standard” still applies in that it would be a standard across the consumer group.
  3. Resource pooling: Also known as multi-tenancy, this characteristic requires that the cloud serve multiple consumers, and that the resources be dynamically assigned in response to changes in demand.  The definition goes on to say that there is also a sense of location independence in that the consumer has no control over the location where the computing takes place.  It is important to distinguish “control over” from “knowledge of”.  The consumer may well know which specific data centre the resources are running in, particularly in the case of a private cloud.  There may also be limitations for compliance or security purposes on where the resources can be drawn from.  The important point is that the consumer cannot pick and choose between resources of a particular class; they are assigned interchangeable resources by the provider, wherever they happen to reside, within the limits of the service agreement.
  4. Rapid elasticity: Capabilities need to be rapidly provisioned when demanded.  The definition does not specify how rapidly, but the intent is that it be in a matter of minutes at most.  The service must be able to scale up and back down in response to changes in demand at a rate that allows potentially unpredictably varying demands to be satisfied in real time.  Ideally, the scaling is automatic in response to demand changes, but need not be.  The definition then goes on to say that the resources often appear to be infinite to the consumer and can be provisioned in any quantity at any time.  This is of course not a rigid requirement.  A cloud service could put an upper bound on the resources a particular consumer could scale to, and all clouds ultimately have a fixed capacity, so this clearly falls in the “grand illusion” category.
  5. Measured service: The NIST definition specifies that cloud systems monitor and automatically optimize utilization of resources.  The definition does not specify the units of measurement, and in fact Amazon and Google’s cloud services meter and charge using very different models (in thumbnail, Amazon in terms of infrastructure resources and Google by page hits).  What is surprising is that the definition does not state that the consumer is charged in proportion to usage, which many definitions consider the most fundamental tenet of cloud computing.  The NIST definition allows a situation, for example, where several consumers (say, members of a trade organization) decide to fund and build a computing facility meeting the five requirements and share its use, but don’t charge back based on usage even though it were possible.

There’s a lot to like about the NIST definition and it is the one I’ll be using in subsequent articles.  We’ll be digging into what people and organizations are actually doing with cloud computing (without all the hype and hyperbole), and practical considerations for success from both the business and technical viewpoints.

Larry Simon is an IT strategist who has advises startups through to Fortune 500 corporations and government institutions on achieving maximum return from their information technology investments through sound governance and practices.

Should Business Strategy be Influenced by Technological Considerations?

Can business strategy be created in isolation of the technology considerations? There is a widespread belief in the Business Community that Business Strategy comes first and then technology follows in some way to support that business.

In my experience the common perception among organizations is that Business defines its strategy first and then technology enables the strategy.

Strategy Development Process:

In order to explore the role technology plays in shaping and supporting the business, let’s look at how strategies are developed.  There has been a significant amount of research done and published in understanding how strategies are developed.  Here are some relevant highlights.

There are two main dimensions to strategy development.

  1. Visionary thinking based on intuition, a sense, an ability to make bold predictions and define goals.
  2. Strategy development is largely based on scientific analysis, considering options and recommendations based on the analysis followed by implementation.
    • Strategic Analysis guided by scientific approach understanding your markets, competitors, value chain, bargaining power of the key stakeholders.  It also entails understanding the strengths and weaknesses of your organization against the opportunities and threat that the external environment presents
    • Strategy Formulation guided by analytical findings, alignment to the vision and overall goals of the organization to create a strategic road-map
    • Strategy Implementation is of course converting the strategy to real results by successfully implementing the strategy

It is the strategy development that is the focus of this article. Specifically, strategic analysis which then guides the strategy formulation and implementation.

Is there a place for technological consideration in strategic analysis? The answer is quite apparent as demonstrated through examples next.

Technological Influences on the Business Landscape

Examples of technologies that have had transformation impact on business value chain and have redefined markets and distribution channels are all around us.

The globalization phenomenon enabled by the internet is one of most profound. The Internet has impacted all the traditional dimensions of business strategy (reduction in barriers to entry, increased market size across the globe without limitations of geographic divide, increased competition etc.).

Financial services industry is a prime example of an industry where technology has transformed the value chain, redefined competitive forces and given the consumers tremendous amount of bargaining power.  Entry barrier have been declining, new competitor have emerged. Some financial products and services have become more transparent and commodities making the market more competitive. Internet as a tool to create a new service delivery channel (reduced channel costs, 24 by7 availability) has put pressure on the more traditional branch based channels. The resulting service delivery cost structure has changed. ING is operating on the model that bricks and mortar are not required to sell its banking products and services.

Healthcare value chain has been transformed by technological advances, linking healthcare records through electronic information exchange, diagnostic imaging from traditional film based to digital imaging has redefined the value chain and changed the balance of power between the suppliers, buyers not to mention the very nature of the products and services being delivered.

Retail Industry is another such example where technology has changed the business landscape.  Amazon’s strategic business model was completely defined by technology.

Relationship between Business and Technology

Given how profoundly technology has influenced our business and personal lives, it is hard to fathom how a successful business strategy can be defined without considering technological influences and enablers.  By creating a partnership between Business and Technology at the Strategy development stage, you are creating a strategy that is well formed and can maximize business value and competitive positioning by embedding technological considerations from the very start (and not an after thought!).

So why is it that there is a significant divide between the Business and Technology?  In subsequent articles, I will focus on why there is this barrier (real or perceived) that creates this divide between Business and Technology.

If you have examples to demonstrate the benefits of business/technology partnerships, please share your thoughts on this forum.