APPRAISE - Fraud Detection
at a Glance
Find a better way to outsmart fraud
APPRAISE is an automated health insurance web application which determines the risk of fraud and individual ancillary claims abuse.
APPRAISE is designed to calculate multiple probability-based measures.
HCF Health Insurance | www.hcf.com.au
HCF is Australia’s largest not-for-profit health insurer, currently covering approximately 1.4 million Australians. HCF’s total assets are worth approximately $1,277 million.
Find a better way.
The Provider and Claims Compliance division of HCF investigates up to 400 potentially fraudulent cases each year. To do so, the HCF team uses information sourced from staff, its fund members, health service providers and the general public.
However, this methodology limited the available time for the skilled HCF staff to focus on cost-effective interventions.
HCF needed a better way to reduce the time and costs associated with triaging the extensive and disparate information.
To determine the risk of fraud and claims-abuse, Houston We Have Prometheus created an automated bespoke fraud identification system – APPRAISE.
Based on research and experience in the identification of potential fraud or claims abuse, the HCF staff specified seven indicators.
APPRAISE to calculate multiple probability-based measures.
APPRAISE incorporated these indicators to rank individuals and identify how individuals compare to their peers in terms of the risk and fraud indicators.
Presented as a dashboard with graphs, this information alerts the HCF investigators to the potential need to audit
Since the implementation of APPRAISE, HCF has been able to increase the number of meaningful fraud audits by 68%.