Achmea, a large insurance provider in the Netherlands, and nonprofit Netherlands health insurer CZ have each selected the SAS Fraud Framework for Health Care to reduce costs and fraud within their organizations.
The insurers will be able to uncover fraudulent claims faster than was previously possible, ultimately helping to reduce health care costs, according to SAS.
To help get rising health care costs under control, CZ developed the cost management program Zorgkostenbeheersing 2.0, with an important goal being to quickly detect, investigate and report on erroneous or unjustified claims.
“Rather than focusing on fraudulent activity after the fact, we now address it early on in the process,” said Fleur Hasaart, program manager at CZ. “That way, we can take pre-emptive measures and proactively detect false declarations or fraud before we pay out claims.”
CZ integrates all relevant information relating to health care claims and costs within the framework, creating a complete picture of a health care provider. “By analyzing these profiles using the hybrid detection method of the SAS Fraud Framework combining rules, anomaly detection, predictive models and social network analysis we can quickly spot when treatments and declared costs deviate from the norm,” Hasaart said. “The solution also goes one step further and provides us with answers to questions we haven’t yet asked; and network analysis helps us gain additional insights, which may necessitate further research.”
