System assisted risk management

11-04-2012 |

A repetitive and tedious analysis of the company work is necessary to assess the risks and prevent disasters.

Such data analysis includes:

  • Setting up macro-management risk indicators
  • Fraud and Abuse
  • Fraud Cliques detection
  • Comparative studies
  • Loss ratio
  • Granted approvals analysis
  • Denied approvals analysis
  • Medical cases distribution (geographically \ age group \ cost groups)
  • Services distribution (geographically \ age groups \ price group)
  • Claims distribution (period \ location \ age groups)
  • Claim processing analysis
  • Weekly and monthly targets
  • Approvals average processing time
  • Medical network
  • Geographic Coverage
  • Diversity of provider types

Tria METIS provides the TPA \ Insurance Company management with the E-Risk Officer.


E-Risk Officer

  • Extremely high reporting capabilities taking data analysis to a whole new dimension
  • Customizable macro-management risk indicators
  • E-Risk Officer allows the super user to setup and manage macro-management indicators according to the company vision and strategy
  • Automatic Notification Engine
  • E-Risk Officer will automatically notify (Email, SMS) the designated management when a risk is assessed and considered eminent.
  • Automated loss ratio and health plan assessment
  • Automated Abuse and Fraud assessment

Using business intelligence technology and well-crafted algorithms our solution is able to indicate:

  • Inter-provider cliques
  • Provider-beneficiary cliques
  • Potential abuse

Our risk assessment engine will narrow down the set of potential abusers giving the inspection and investigation department the necessary circumstantial evidence to investigate and take action.

  • Monitor internal flow of work
  • Senior officers shall be able to assess the efficiency of their teams on a daily basis.
  • Claim Processing in terms of time and numbers
  • Approval processing:
  • Average time per approval request
  • Number of processed approvals per day
  • Medical network
  • Growth
  • Coverage
  • Timely payments

Advantages

  • Increase the ability to prevent a risk by carefully choosing your macro management indicator.
  • Supervise the internal flow of work and estimate the expected targets.
  • Reduce the cases of fraud and abuse
  • Supervise your company from anywhere around the world