SAS® Fraud Framework helps Dutch insurer CZ control health care costs
Nonprofit Netherlands health insurer CZ has selected SAS® Fraud Framework for Health Care to help prevent fraud, waste and abuse.
The solution from business analytics leader SAS enables CZ to uncover fraudulent claims faster than was previously possible, ultimately helping to reduce health care costs.
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,” noted Hasaart. “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.”
SAS Fraud Framework helps CZ work more efficiently, said Hasaart. “It’s a learning solution, meaning that when we identify and correct a discrepancy, the quality of what we subsequently detect also improves.”
Onno de Vrij, Risk and Fraud Manager at SAS, noted “Waste and fraud are high on the agenda of regulators and insurers alike. To face these challenges, they need a solution to help check whether health care claims are lawful. SAS software’s combination of data analysis, data mining and network analysis is indispensable and provides CZ with a powerful tool to effectively combat misuse of health care facilities.”
CZ will implement its health cost management program over three years. SAS Fraud Framework for Health Care is the project’s first step. In the next phase, the company will contact policyholders to confirm that services rendered by caregivers match the claims filed. This is another area where CZ can use SAS to gain further intelligence about health care providers after signals from policyholders.
Achmea also opts for SAS®
Achmea, another large insurance provider in the Netherlands, also recently selected the SAS Fraud Framework for Health Care to reduce costs and fraud within its organization.
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