TORONTO, ONTARIO (WEDNESDAY, MARCH 6, 2019) – With health benefits fraud reaching increasingly sophisticated levels, detecting and shutting down fraudulent schemes means sifting through unprecedented levels of collusion. Perpetrators of fraud have become more well-versed in the benefits world, more technology savvy and more innovative. Their activity can be vast and varied, and often include some combination of health providers, plan members, prescribers and labs/suppliers, adding up to hundreds of millions of dollars each year.1
As a long-standing leader in fraud prevention and detection, Green Shield Canada (GSC) and HBM+ (its health benefit management solutions provider division), are staying a step ahead with a multi-layered strategy centred on artificial intelligence (AI) and housed under the new Claim Watch banner.
While today’s range of claims data—which comes in a huge volume in all forms and from all directions—can be extremely time consuming to analyze, the new AI platform not only finds and compiles all kinds of data at tremendous speeds, but also identifies patterns and less obvious outliers at a deep enough level to unearth suspicious activity earlier than in the past.
“We’re very proud of what GSC and HBM+ do in the fraud detection and prevention space,” explains Brent Allen, GSC’s vice president of service operations. “In the past, preventing and detecting fraud involved manual processes… essentially the focus was on following a paper trail. We were trying to find a needle in a haystack.”
“Fast forward to today and our AI platform is a game-changer in bringing together all our data on claims, health providers and plan members to form instant insights. The richness of our data is a true differentiator in our industry, and that haystack quickly becomes less daunting with an AI-powered microscope.”
Still, the AI platform is just part of the Claim Watch story. It starts with the fact that all claims are paid on the Advantage® system so data flows through a single system (and established claims management policies) to the AI platform without being outsourced. In turn, our industry’s most robust provider registry ensures that the applicable credentials and licences are in place for any provider submitting claims online via the providerConnect® portal.
“Whether we are identifying pure fraud or benefits misuse, GSC is focused on protecting our plan sponsors’ benefit plans and helping them extract the maximum value from their benefits spend. And HBM+ brings value to its carrier and claim paying TPA partners by staying at the front of the parade when it comes to technology, innovation and fraud management,” Allen adds. “Claim Watch plays a key role in delivering on this commitment.”
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1 The Canadian Life and Health Insurance Association (CLHIA) estimates that in North America two per cent to 10 per cent of all health care dollars are lost due to fraud.
About Green Shield Canada
GSC is Canada’s only national not-for-profit health and dental specialist, and their reason for being is the enhancement of the common good. GSC seeks innovative ways to improve access to better health for Canadians. From coast-to-coast, their service delivery includes drug, dental, extended health care, vision, hospital and travel benefits for groups and individuals, as well as administration services. Supported by cost containment strategies, advanced technology and exceptional customer service, they create customized programs for over two and a half million plan participants nationwide. greenshield.ca
HBM+ is more than a pharmacy benefits manager, it is a health benefits manager. With offices in Quebec and Ontario, HBM+ provides customized white-label solutions that support drug, dental and extended health benefits for group benefits carriers, third-party payors, and government organizations across Canada. HBM+ is built on a foundation of proven technology, seamless branding, innovative claim management and administration capabilities, collaborative provider management, and solid industry expertise. They recognize that each client is unique and requires a business solution tailored to their needs. hbmplus.ca