In the media

New payment integrity platform to cut healthcare fraud in Southern Africa

01 September 2015

Partnership between AfroCentric's Helios ITS and FICO pioneers a new approach to improve the integrity of SA's healthcare system.

The AfroCentric Health Group (AfroCentric) announced a strategic partnership that establishes the South African healthcare industry's first leading fraud management solution.

The partnership sees AfroCentric's heathcare IT services subsidiary, Helios IT Solutions (Helios ITS) and global analytics software provider, FICO, joining forces to offer an industry-leading fraud management and payment integrity platform to all medical schemes in Southern Africa.

FICOTM Insurance Fraud Manager (IFM) uses world-class analytics models that are integrated within purpose-built software, allowing medical schemes to have a vastly enhanced ability to identify and address existing and emerging losses from fraud, waste and abuse. Deployed through Helios ITS' secure technological offering, it will dramatically enhance medical schemes' ability to detect, review, decision and investigate suspicious claims and providers and set the standard in South Africa for delivering cost-effective quality care with integrity.

Says Paul Midlane, AfroCentric's General Manager of Legal Governance and Risk Compliance: "Healthcare fraud is on the rise, accounting for between 10 and 20% of gross healthcare claim payments globally according to KPMG. Considering the World Health Organisation estimates that South Africa spent R376 billion on healthcare in 2011 alone, substantial losses are occurring within an industry already plagued with rising costs. It is time to address and ensure the integrity of the South African healthcare system. Controlling healthcare losses to fraud, waste and abuse will only further improve the access, cost and quality of care for beneficiaries."

The primary focus of Helios ITS is on offering technologybased solutions that streamline administrative processes to create efficiencies and sustainability of the South African healthcare industry. This latest partnership with FICO demonstrates a meaningful stride towards starting to solve an industry-wide scourge of financial loss.

Says Helios ITS spokesperson, Vijay PiIlay: "Finding a solution to countering healthcare fraud effectively in South Africa has been regarded by many in the industry as the silver bullet for decades now. After extensive examination of FICO's Insurance Fraud Manager (IFM) solution, we are really excited about the benefits and impact we anticipate by enabling schemes to reduce these losses and free up massive resources for better patient care."

Says FICO spokesperson, Derick Cluley: "We've worked with healthcare insurers all over the world, and our approach has proven itself over decades to effectively reduce fraud in other industries too. Twenty years ago FICO's analytics-based approach to detecting and managing fraud revolutionized the credit card industry, reducing fraud by over 70% since that time.

"FICO's healthcare platform has a similar history. From the beginning we've been convinced that healthcare fraud is fundamentally different from that in other industries. The payment process is more complex, involving more parties, and the role of the consumer is dramatically different. Addressing all these subtleties, the IFM solution not only offers financial benefits and improved care, it also allows for improved governance, regulatory compliance and transparency which will position users of the platform as best-in-class."

The cutting-edge fraud detection system employs predictive analytics to detect and reduce fraud, waste and abuse at the claim level (pre-payment or post-payment) and provider level (retrospective post-payment). Importantly, the solution also enables schemes to augment their existing payment integrity capabilities.

Midlane concludes: "Schemes will be able to avoid losses upfront through catching aberrant claims prior to payment and they can focus investigative resources where they produce the greatest financial impact. This will undoubtedly be welcome news for the industry."

Source: Newsclip