01
RULE DEFINITION, IMPLEMENTATION & MANAGEMENT
Our game-changing rules engine and Artificial Intelligence (AI) learning module automates, mimics and improves human decision making. It guarantees a 100% accurate, consistent and integrated process, every time.
The engine is fully customisable to Client requirements and requires little hard-coding or programming expertise. This means reduced application maintenance costs, reduced resource costs and an unmatched speed to market.
All rules are built on Evidence Based Medicine (EBM) as supported by local and international learned associations. We also ensure that the system caters to regional regulatory aspects with full adherence and compliance to governance processes and regulations guaranteed.
02
PATIENT DRIVEN CARE
Patient Driven Care is our globally unique health risk management approach that results in healthier customers, and more effective clinical and financial outcomes. It is a deep understanding of risk, allowing us to expertly manage it at all levels. It also informs our every customer interaction where our base knowledge of their potential needs is accurate, relevant, and impactful.
Through Artificial Intelligence and Machine learning, our system risk rates each customer based on every available data point. This creates individualised e-files and each customer is assigned to a risk category.
From there, we empower our Clients to become actively involved in their customers' healthcare journeys and lend a helping hand when needed. For low risk, or healthy members, we have a dedicated Agile Care approach. The objective is to actively help them maintain their good health, and we do this through various Client-specific engagement strategies.
High risk members are more actively managed to make sure they remain as healthy as possible, for as long as possible. The ultimate objective is to circumvent avoidable hospital admissions and we do this by assigning a Personal Health Coordinator. Interventions range from proactive discussions about their health, guiding them to centres of excellence, or helping them to identify the best contracted facility for their unique risk profile.
This means that your customers, from the healthy to the not so healthy, experience a consistent and unprecedented level of service and care, while associated risks are expertly reduced.
03
PRE-AUTHORISATION & CASE MANAGEMENT
Pre-authorising hospitalisation (and other defined procedures) is a powerful risk management strategy that we use to prevent unnecessary claims and empower better claims assessment for our Clients. It also prioritises MORE CARE through proactive customer engagements that explains if, and exactly how, their procedure will be covered.
As an automated process, the pre-authorisation system is built on our vast IP, clinical knowledge, ICD10 and TOSP codes. It also considers patient-specific policies and benefits, history, exceptions, exclusions and Appropriate Level of Care (LOCs).
Case management naturally flows from the pre-authorisation process. The embedded system intelligence pre-emptively identifies and escalates any authorisations that deviate from the norm such as high cost or clinically complex cases.
From there, we empower our Clients to adopt a MORE CARE. LESS RISK philosophy through proactive interventions. Designed to reduce recurrent event rates, these typically include admission reviews, as well as patient discharge planning and management.
04
CLAIMS RISK MANAGEMENT
Our Pre-Authorisation and Claims process is fully automated and applies more than 67 000 rules, algorithms and protocols, as well as AI machine learning processes. Every healthcare claim is adjudicated in milliseconds, in real time, at the lowest granular level and at 100% accuracy. All possible irregularities - including fraud, waste and abuse - are immediately flagged for further investigation before payment is made.
We also pre-emptively flag any clinically inappropriate items and ensure it adheres to benefit schedules, Evidence Based Medicine protocols and treatment guidelines.
As a result, we achieve impressive reductions in fraudulent claims, incorrect processing and inconsistent benefit provision. At the same time, operating costs are reduced, risks are expertly managed and underwriting ratios are improved. From a customer perspective, funding decisions are 100% consistent and aligned to their chosen health insurance product.
OUR SOLUTIONS
RISK
MANAGEMENT
