AfroCentric, FICO partner to offer payment integrity platform to reduce healthcare fraud in South Africa

FICOAug 20 2015

Highlights:

• 10-20 percent of paid healthcare insurance claims estimated to be fraud, waste or abuse
• FICO and AfroCentric Health's Helios IT partner to launch South African healthcare insurance fraud, waste and abuse solution and drive down losses
• Adaptive predictive analytics in new solution detect abnormalities at the claim, provider and procedure level

The AfroCentric Health Group (AfroCentric) and global analytics software firm FICO today announced a strategic partnership that establishes the South African healthcare industry's leading fraud management solution. AfroCentric's healthcare IT services subsidiary, Helios IT Solutions (Helios ITS), and FICO now offer this fraud management and payment integrity platform to all medical schemes in South Africa.

FICO^® Insurance Fraud Manager uses adaptive predictive analytic models that are integrated within purpose-built software, giving medical schemes (payers) a vastly enhanced ability to identify and address existing and emerging losses from fraud, waste and abuse. Medical schemes can use this solution, deployed through Helios ITS' secure technological offering, to detect, review and investigate suspicious claims, members and providers, and deliver cost-effective quality care with integrity.

"Healthcare fraud is on the rise, accounting for between 10 and 20 percent of gross healthcare claim payments globally according to KPMG," said Paul Midlane, AfroCentric's general manager of Legal Governance and Risk Compliance. "Based upon World Health Organization 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 ensure the integrity of the South African healthcare system – not only to stem losses, but also to improve the access, cost and quality of care for the people of South Africa."

The cutting-edge fraud detection system employs predictive analytics to detect and reduce fraud, waste and abuse at the claim, provider and procedure levels. Importantly, the solution enables schemes to augment their existing payment integrity capabilities.

Said Helios ITS Managing Director Vijay Pillay: "Finding a solution to counter healthcare fraud effectively in South Africa has been regarded by many in the industry as the silver bullet for decades. After extensive examination of FICO's Insurance Fraud Manager 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. This partnership with FICO demonstrates a meaningful stride towards solving an industry-wide scourge of financial loss."

"We've worked with healthcare insurers for decades, and our analytic approach has proven itself time and again," said Derick Cluley, FICO's country manager for South Africa. "The healthcare payment process is complex, dynamic and involves many parties. FICO's payment integrity solution accounts for this and offers opportunities for dramatic reduction in fraud, waste and abuse losses, improved governance, regulatory compliance and transparency, and improved productivity."

"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," Midlane said. "This will undoubtedly be welcome news for the industry."