Case studies.

“The noblest pleasure is the joy of understanding”

Leonardo Da Vinci, 16th Century Polymath

APPRAISE - Better Provider
profiling for health funds

The Problem
at a Glance
How to help health funds detect unusual behaviour in ancillary providers before it becomes a problem.
APPRAISE (by Prometheus) is an automated tool for Health Funds. Using multiple probability-based measures, it analyses ancillary provider claims behaviour to help prevent minor issues becoming major problems.
The Profile
There are more than 35 health insurance funds active in Australia providing hospital cover to more than 11 million people and some form of private treatment cover to more than 13 million.
The Challenge
How to improve claims quality and ensure ancillary providers operate with accuracy and in line with fund principles. Funds typically use information sourced from staff, fund members, health service providers and the general public to assess provider claim veracity and accuracy. This can be time consuming, labour intensive and highly manual. Health funds need a better way to reduce the time and costs associated with triaging the extensive and disparate information that’s available.
The Solution
To determine which providers warranted increased monitoring, reminders of procedures or other forms of intervention, Houston We Have Prometheus created an automated and bespoke system for profiling ancillary providers – APPRAISE. Based on research and experience in the identification of claims errors and other forms of potentially problematic behaviour, seven indicators were identified. APPRAISE calculates multiple probability-based measures to rank individual providers versus their peers against these indicators. Presented as a dashboard with graphs, this information alerts health funds to the potential need to audit and or investigate further. This advanced warning systems means health funds can help drive desired claims behaviours rather than apply punitive measures once problems occur.
The Result
APPRAISE is helping funds achieve significant reductions in claims waste, improvements in claims quality and the reduction of fraud.