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Dental claims administrator deploys BI to slash fraud and costs

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Dental claims administrator Denis has slashed claims fraud and reduced its operating costs by using in-memory business intelligence (BI) software QlikView to analyse information on the 1.3-million medical scheme members it manages.

“Overall, about 10% of all transactions in the medical schemes industry are fraudulent,” says Denis MD David Carolus. “Over-claiming or claiming for procedures that were never performed is not uncommon. Previously we could eliminate some fraud by actively managing patients using our specialist knowledge.
"Now QlikView has helped us reduce fraud even further, because it’s much easier to spot anomalies in the data.”
Carolus says QlikView offers instant access to detailed data on 2 300 dental practices and hospitals around the country.
“I can look at what’s happening per practice, per hospital, per dentist and even per theatre. I can ask questions like ‘Why does Dr X take so long in theatre and why is it always longer when his anaesthetist is Dr A than when it’s Dr B?’ The system is that intuitive.”
Previously, says Carolus, it was difficult to extract meaningful information from the data Denis held. “To investigate one issue we’d need to send out ten queries and would get ten reports back, all at different times, which then had to be assimilated so that one person could make a decision – and by that time it was usually too late. Time lost in getting data to support making a good decision is very expensive.
“Now we have instant access to timely, accurate information. It’s hard to quantify the benefit of that, but we have definitely saved by having shorter planning time frames, more accurate projections and much better information retrieval and decision making.”
In addition, Carolus adds, Denis has cut its direct costs by 10% and the software paid for itself in four months. The fact that all managers now have access to identical, up to date, accurate information has also improved the quality of decision making in the business.
The clinical risk management and forensic audit departments at Denis, now run entirely on QlikView. The software, which was implemented in just a month, pulls together data from sources including clinical, financial and forensics databases, Excel spreadsheets, call centre records and insurance information.