Tag: Data Science

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.