Pradhan Mantri Jan Arogya Yojana – Vidal Health Insurance TPA Pvt. Ltd.


SKOCH Award Nominee

Category: Services – Medium Enterprise
Sub-Category: subServices – Medium Enterprise
Project: Pradhan Mantri Jan Arogya Yojana
Start Date: 2018-09-23
Organisation: Vidal Health Insurance TPA Pvt. Ltd.
Respondent: Ms Ajitha Menon, Chief Operating Officer
https://pmjay.gov.in/
Level: Club Plus


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Case Study

Fraud Detection in Insurance

Introduction:

Vidal Healthcare Insurance TPA PVT LTD has a Risk management Team that has developed a tool that is used to run vigorous triggers on the insurance claims data. This tool has helped to reduce fraud in insurance claims in Public schemes such as Ayushman Bharat

Problem:

There was a high occurrence of insurance claims fraud in public schemes such as Ayushman Bharat. The lack of any technological solution to detect fraud was making it difficult to ensure that the benefits of these schemes reach the correct beneficiaries.

Solution:

A system was developed that analysed claim data and detected suspicious claims, this helped to evict any fraud claims. This system also included a medical audit of all the claims to eradicate any possibility of fake claims being made. A mobile app was also developed that eased the job of the field auditor.

Outcomes:

As a result of the implementation of this project, there was a huge decrease in the number of fraud cases. This ensured that the benefits of public health insurance schemes reach the right hands

Challenges:

The lack of any technological solution to track the entire claims and settlement process was a big challenge.

Innovation:

The deployment of analytical tools that ruled out fraud cases by studying the data, and system-based triggers that select cases for medical audit.

Opportunities:

The project has potential and it can be implemented to reduce fraud in several other public insurance schemes.

Summary:

The creation of analytical and technological tools to detect fraud claims happening in public health insurance schemes such as Ayushman Bharat.


For more information, please contact:
Ms Ajitha Menon, Chief Operating Officer at ajitha@vidalhealthtpa.com


(The content on the page is provided by the Exhibitor)

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