It is a truth universally acknowledged, that healthcare needs to be improved at many levels. Yet, it is rarely known how much transformation journey is needed to make healthcare more focused on what really matters, people health. The price of not doing so can be estimated in dollar value - but, more importantly, in death, pain, and disability that could have been avoided.
On a global scale around 10% of the Gross Domestic Product (GDP) is allocated for healthcare spending which accounted for +7.2 trillion USD in 2015. Shockingly enough, a considerable chunk of this amount is wasted which was estimated to be 30-35% in one of the most advanced healthcare systems in the world, the US. In fact, the fraud, waste, and abuse (FWA) in medical claims account for 15% of the total healthcare spending making a drastic impact on the global healthcare that accounts for 1 trillion USD. FWA includes for instance:
• Performing an unnecessary or inappropriate service.
• Billing services, procedures and/or supplies that were not or partially provided.
• Billing a higher-level procedure code than is supported by the record (upcoding).
• Charging in excess of usual fees.
Tackling this problem on a scale require in-depth exploration of market-specific context, considerable understanding of major FWA themes, and a robust way of dealing with the exponentially growing insurance claims data. To make this possible, our PhDs, medical doctors, and business executives researched 2 million medical claims and developed cutting edge solution using deep reinforcement learning, advanced data science tools, and predictive analytics.
Our AI driven claim solution, AiClaim is now finding its new home in one of the largest Third-Party Administrators (TPA) in the UAE to test, deploy, and enhance their abilities to manage FWA in an intelligent way that goes beyond the traditional rule book. We want to contribute to the rise of a new healthcare system that is much rational and value-driven on a scale.