IBM Case Studies PRO BTP: Analytical tools used for real-time detection of suspicious claims for medical expenses

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	PRO BTP: Analytical tools used for real-time detection of suspicious claims for medical expenses IBM

PRO BTP: Analytical tools used for real-time detection of suspicious claims for medical expenses

IBM

Technology Category	Analytics & Modeling - Predictive Analytics Application Infrastructure & Middleware - Data Exchange & Integration
Applicable Functions	Procurement
Use Cases	Fraud Detection
Services	Data Science Services System Integration
Challenge	PRO BTP is the social protection group for French building and construction professionals. It offers members (employees, retirees, craftsmen and construction companies) services in the areas of pension and health insurance (provident, health and savings). The firm had been using a processing system that was identifying unjustified health claims only after they had been paid. To reduce system abuses and better control expenses, PRO BTP needed to detect suspicious claims before the company reimbursed health professionals. Read More
About Customer	Based in Paris, PRO BTP is France’s first social security provider for the construction and civil engineering industries. The group supports nearly 3.10 million members, providing products and services that include complementary retirement, non-life and life insurance, health services, savings, leisure and social activities. Read More
Solution	Teaming with PRO BTP, IBM developed a secure service platform dedicated to detecting, categorizing and fighting fraud, service abuses and errors. Thanks to a detection engine validated by experts, this service platform, named Solon, analyzes optical and dental reimbursement claims in real time so that the firm can evaluate them before payment or before establishing a charges agreement. The platform features enriched predictive models that it can use to help detect fraud networks, and it is based on self-learning technology that pools detection schemes and takes advantage of an observatory watch. Read More Log in to view content
Contents

Technology Category

Analytics & Modeling - Predictive Analytics

Application Infrastructure & Middleware - Data Exchange & Integration

Applicable Functions

Procurement

Use Cases

Fraud Detection

Services

Data Science Services

System Integration

Challenge

PRO BTP is the social protection group for French building and construction professionals. It offers members (employees, retirees, craftsmen and construction companies) services in the areas of pension and health insurance (provident, health and savings). The firm had been using a processing system that was identifying unjustified health claims only after they had been paid. To reduce system abuses and better control expenses, PRO BTP needed to detect suspicious claims before the company reimbursed health professionals.

About Customer

Based in Paris, PRO BTP is France’s first social security provider for the construction and civil engineering industries. The group supports nearly 3.10 million members, providing products and services that include complementary retirement, non-life and life insurance, health services, savings, leisure and social activities.

Solution

Teaming with PRO BTP, IBM developed a secure service platform dedicated to detecting, categorizing and fighting fraud, service abuses and errors. Thanks to a detection engine validated by experts, this service platform, named Solon, analyzes optical and dental reimbursement claims in real time so that the firm can evaluate them before payment or before establishing a charges agreement. The platform features enriched predictive models that it can use to help detect fraud networks, and it is based on self-learning technology that pools detection schemes and takes advantage of an observatory watch.

Impact #1	The POC was highly successful, identifying new cases and configurations of fraud that PRO BTP was unaware of. The solution will help the company avoid payment of suspicious claims while speeding the payment of valid claims, potentially saving millions in cost avoidance.

Impact #1

The POC was highly successful, identifying new cases and configurations of fraud that PRO BTP was unaware of. The solution will help the company avoid payment of suspicious claims while speeding the payment of valid claims, potentially saving millions in cost avoidance.

Benefit #1	During the POC, the solution identified 9 percent of optical claims and 14 percent of dental claims as suspicious.

Benefit #1

During the POC, the solution identified 9 percent of optical claims and 14 percent of dental claims as suspicious.

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Overview

PRO BTP: Analytical tools used for real-time detection of suspicious claims for medical expenses

Operational Impact

Quantitative Benefit