Health operators accelerate investments in technological solutions to make preventive processes more agile and efficient
Telemedicine has gained traction during the pandemic and the number of online consultations has quintupled in the last two years. Estimates show that the 5 largest operators in the country carried out an average of 1 million online consultations each during 2021, which led to the acceleration of digital transformation in the sector. In addition to the heavy investments in technology to meet the new demands, the segment still suffers from the increase in costs caused by the growth of reimbursement requests and fraud.
According to Daniel Gusson, Head of Commercial Insurance at Neurotech, before there was a bureaucracy that discouraged the request for reimbursement, made via letter to the company's branch. “Now everything is done online, which facilitated the process and increased the number of requests as well as possible fraud”, he says.
In 2021, the number of claims has jumped and, on average, 3 million claims generate more than R$ 2 billion in costs for the top 5 group of insurers. The average refund amount is around R$ 750.00. In 20% of the total orders some type of fraud is currently identified. But the percentage can approach 60% when a more effective calculation is carried out using artificial intelligence. “With our solution, the identification of abuse and fraud was 2.7 times higher”, highlights Gusson.
The artificial intelligence system is responsible for automating operations, querying and combining internal and external data – from public and private sources – such as DataSus, ANS, among hundreds of other authorized sources available, making use of Big Data and segmenting them according to the policies pre-defined by the company that adopted the technology. From this analysis, the order receives a fraud score.
The higher the score, the greater the probability that the request has some irregularity. “Among the 10% of the highest scoring orders, 92% presented an item with fraud detected by the audit”, he explains.
Frauds involve cases such as issuing two or more invoices so that the refund is full, changing the amount of the receipt for a larger refund and cases where the beneficiary allows someone else to use their plan. “These irregularities are one of the main problems faced by operators and the ways to defraud are constantly updated. In general, our experience helps to act in prevention”, says Daniel.
Neurotech is a pioneer in the creation of advanced artificial intelligence solutions and has applied its technology of analysis and interpretation of large volumes of data to improve services in the Health area.
