machine learning

High time to reduce medical claim abuses in the Middle East

Healthcare fraud is increasing day by day in the Middle East countries. Reports show that about 30% of healthcare companies’ expenditures are based on a fraudulent medical claim. Firstly, let us know about the definition of healthcare abuse in the Middle East. It is basically the usage of unethical practices which does not follow prescribed clinical standards and leads to the unnecessarily high expenditure for healthcare. For example, a doctor may prescribe a particular treatment which is not necessary or some patients may claim money for certain treatments which are not being covered by healthcare insurance companies. Nowadays, these practices are very common and most companies are facing healthcare abuse in the Middle East. Some reports show that over 5% of all medical claims are wrong and illegitimate in the United Arab Emirates. These wrong claims done by certain people have led to increasing of premiums of these insurance companies and thus medical claims are becoming quite unaffordable for residents in the Middle East countries. According to the reports, this will lead to an increase in the overall cost of healthcare insurances in the UAE by approximately 15%.

Time has arrived to detect healthcare abuses and reduce overall healthcare cost in the UAE. NETCETERA, a Swiss software company has developed a medical claim abuse detection system called RISIC with the help of machine learning. This detection system RISIC is based on an analysis of about 400,000 real-world data, which learns from its own experiences with these data and helps in detecting frauds up to 50%. This medical claim abuse detection system helps in monitoring suspicious  customer behaviour  and reports them to insurance companies. Thus, through this software, false treatment records can be identified and claims for treatments beyond insurance plans can be detected. RISIC also helps in detecting whether treatment prescribed by a doctor is necessary. Various researches done by RISIC have found that when some doctors do not want to take risks, they prescribe the costliest treatments which prove to be inappropriate.

According to various reports, over-prescription is one of the vital causes of healthcare abuse and is making the UAE a very risky market for Insurance companies. NETCETERA uses RISIC calculator to detect genuine real-world data by taking into account the total number of claims faced by a specific insurance company per year. “RISIC calculator” calculates the  potential saving   for an insurance company via false claims by using denial percentage of the company and the number of claims per year faced by it. RISIC calculator thus reduces the loss faced by an insurance company per year by properly detecting its illegitimate expenditures and also increases the proper denial rate of the company.