You ever hear about the "rent-a-patient" scheme hatched by a pair of unscrupulous doctors in the LA area? In this incredible-but-true scheme, the doctors performed unnecessary surgery on patients that were recruited by marketers with promises of cash or discounted cosmetic surgery procedures.
Patients were instructed by recruiters to describe false and exaggerated symptoms that were used to create medical charts used to make the surgical procedures appear to be justified. The doctors reportedly racked up claims totaling more than $2 million before being caught. Procedures performed on the otherwise normally healthy patients included colonoscopy, sinus surgeries and thoracic sympathectomy, commonly called "sweaty palm surgery."
Claims fraud gives many insurance carriers sweaty palms, as I documented in this recent article in Insurance Networking News. The good news is that technology -- in the form of analytics -- is providing carriers the tools to rapidly sift through claims data to connect the dots on suspicious activities. Time is of the essence -- claims must be paid within a certain period of time, and once the check is cut and mailed, it's difficult to get the money back.
Here's a role SOA can play as well. Sandy Carter, VP with IBM, just published details in CIO about how SOA is enabling MIB, the industry's largest fraud detection service that is used by nearly every North American life and health insurance carrier, to spot fraudulent activity.
Sandy relates that MIB, which has 500 members, can sift through files from a range of systems to help detect potential fraud among new applicants to insurance policies. MIB's systems can access the applicant's insurance and medical history; the proximity of marriage, establishment of a life insurance policy and a spouse's untimely death, and the frequency of auto accidents resulting in medical claims.
MIB is also employing SOA to "help build an online community among credit reporting agencies, healthcare and insurance providers, and government agencies by extracting the information that’s trapped in various software applications that are located inside and outside a company and bringing it together under one roof in a faster, more secure and economical way. This information helps create an accurate and comprehensive credit history profile while also adhering to industry regulations."
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