HCF Case Study

Case Study: Fraud Detection Web Application

HCF Profile

HCF is Australia’s largest not-for-profit health insurer, currently covering approximately 1.4 million Australians. HCF’s total assets are worth approximately $1,277 million. For more information about HCF visit www.hcf.com.au.

Challenge

HCF’s Provider and Claims Compliance division investigate fraud, waste and claims abuse for general treatment claims. The team investigates up to 400 cases each year using information sourced from staff, members, health service providers and the general public.

HCF wanted to reduce the time and costs associated with triaging referrals so that its skilled personnel staff could focus on cost-effective interventions that require higher levels of experience and judgement.

Solution

Prometheus Information was approached to create an automated system to determine the risk of fraud and claims abuse of individuals who transact with HCF. Prometheus  worked with the head of HCF’s Provider and Claims Compliance division to develop a health insurance fraud detection web application called the Ancillary Provider Profiling and Information System (APPRAISE).

APPRAISE calculates multiple probability-based measures to rank individuals who transact with HCF based on seven key behavioural indicators. HCF staff specified these indicators based on research and experience in the identification of potential fraud or claims abuse. The results from APPRAISE’s analyses are presented as a dashboard with graphs that clearly identify how individuals compare to their peers in terms of the indicators. This information alerts the HCF investigators of the potential need to audit.

Result

Since the implementation of APPRAISE, HCF has been able to increase the number of meaningful audits by 68 % and significantly reduced the time taken to triage referrals. The results were immediate and have been consistent to present day.

Testimonial

As a manager of a small team, it is crucial that I am deploying our resources and automating processes as best I can to free up time for the team to utilise their experience and knowledge. This includes eliminating and automating non-value-add activities.

APPRAISE changed the way that we approach the problem. Using the dashboard allows us to determine just at a glance a high risk situation and more importantly, what areas need to be targeted. It has directly yielded significant results for us. It has allowed us to spread the net wider and deploy our resources to those activities where there skill and knowledge adds value.

The team at Prometheus has always been extremely responsive with any problems or issues we’ve come across, right down to the day-to-day issues. They’re more than happy to give us ongoing support and attention and from a customer’s point of view this is invaluable.

Luke Givney, Claims Investigation Specialist, HCF