News - 9 July 2015

Fighting fraud with big data

Every year, health and accident insurers receive several million invoices – health insurance providers’ annual costs add up to around 30 billion Swiss francs. When dealing with sums of this size, a system of control is needed, and one that can pay for itself: both the accident insurer Suva and the health insurance provider Concordia rely on a software solution provided by ELCA to review all their invoices, and save around 100 and 240 million Swiss francs, respectively, every year as a result. This solution has already been featured in a report by the Swiss TV business magazine Eco.

Along with simple mistakes such as incorrect pricing of medication or duplicate statements, the software solution from ELCA also evaluates whether the particular services listed in the invoice, such as medication or treatments, are appropriate for the type of illness concerned, and whether the medication corresponds to the diagnosis and the patient’s age. As an example: you have to go to the doctor with a knee injury after an accident, and the doctor also mistakenly lists a cough medicine on the invoice to the accident insurer, which should actually have been charged to the health insurance provider.

As the Sumex Suite software is utilised by several insurers and reviews over 20 million invoices every year, the solution is able to draw on a large volume of data. A specific module of the solution analyses this data and uses it to build models. Using these models, any new invoices which do not follow a certain pattern are classified as “suspicious” and forwarded to a service specialist for manual review. The results from this manual review then flow back into the models, meaning the software learns from every new invoice it processes. This means the solution’s wealth of knowledge and its memory are constantly being augmented, and the models are based on an ever-expanding reserve of data, cases and scenarios.

In this way, the approach to automated creation of models is combined with the service experts’ knowledge. Furthermore, the efficiency of the models and data sources is regularly reviewed and added to by insurance specialists. As such, the service review is constantly improved, turning big data into smart data.

In the following programme produced by the TV business magazine Eco, you can find out more about this software solution and what it means for the insurance sector:

As the Sumex Suite software is utilised by several insurers and reviews over 20 million invoices every year, the solution is able to draw on a large volume of data. A specific module of the solution analyses this data and uses it to build models.

Testing concrete scenarios in the Big Data Lab

Most companies underestimate the value, and particularly the potential, of the data they have. Combining and analysing data in the right way, even if that data is unstructured, can help to uncover errors or cases of fraud – as in the case of automatic reviewing of invoices. ELCA has already supported many clients in implementing fraud management solutions.

In order for companies to be able to review their data, and especially big data, in a concrete manner, ELCA has founded the ELCA Big Data Lab. The Lab provides a detailed and secure platform for companies to deal with their own data, all under the guidance of ELCA big data experts. This does not require any expensive investments in staff, hardware or software: the client simply supplies their data, and ELCA provides the necessary infrastructure, including technologies, processes and expertise. The Lab makes it possible to test various cases of application and scenarios iteratively using the client’s data, and thus provides indications of sustainable future business cases and which big data investments would really be worth making.

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