Medical Fraud Detection and Prevention System - Article 1

Insurance Companies that are looking to stay on top of competition and minimize losses; employing the power of BI & AI (Business & Artificial Intelligence) is no longer a mere option.

One of the most important BI & AI applications in the insurance industry is the Medical Fraud Detection and Prevention System. Fraudulent Claims are known to cost insurance companies up to 20% of the written premiums which means a huge amount of money that affects not only the insurance companies but also the countries’ economies.

Health insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group. Frauds can be committed by both the members and the medical providers.

Examples of Members Fraud Schema:

  1. Abuse for medical unjustified visits.

  2. Abuse Services

  3. Enrolling someone not eligible for coverage on a health plan(divorced spouse – married daughters)

  4. Member Demographics contradiction

Examples of Medical Providers Fraud Schemas:

  1. Billing for a non-covered service as a covered service

  2. Billing for services not rendered

  3. Misrepresenting dates of service

  4. Overutilization of services.

  5. Waiving of deductibles and/or co-payments (“up-coding”)

During the last 10 years, 3adda, one of the leading BI companies in the field of Insurance Intelligence applications in the MENA region, has proudly helped major companies like Tawuniya in Saudi Arabia, Oman United and Royal Insurance in Egypt to unlock the power of their Information Systems by building intelligent solutions. One of those solutions is its Medical Fraud Detection and Prevention System. The MFDPS can be used directly as a Cloud system by a simple subscribing process or can be totally installed in a few weeks as an add-on layer on top of any current Insurance System.

For more information, call for POC or live demo, we’ll be very honored to receive your requests:

United States Office:

651 N Broad St, Suite 206

Middletown, DE19709

Cell: +1 862 220 7905

Egypt Office:

61 AShgar Compound, App. 11 & 12

Wahat Road, October City, Giza

Cell: +20 112 440 2222

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