Challenge
- With decades of experience managing health services, AdvanceCare had extensive knowledge of Fraud and Abuse, but needed to move forward in automating and systematizing how it was monitored. The company wanted to analyze a larger number of fraud scenarios through automated processes able to detect more suspicious cases and make them available faster, both to internal teams for analysis and to institutional clients, through a simple, fast Business Intelligence (BI) interface.
- Although the company already used ad hoc processes (some still in place, based on BI tools) and behavioral statistical analysis to detect deviant patterns, manual intervention and long response times made it hard to reach the intended goals. An integrated, structured solution therefore became essential, one that would capture the know-how acquired, speed up intervention and minimize impacts.
Solution
- The project began with a company within the AdvanceCare group with extensive know-how of the US and Indian markets in similar projects. This partner identified the fraud scenarios and developed the business rules for detecting cases of potential fraud and abuse.
- The technology solution, implemented by Gstep, consists of ETL processes (approximately 40) that apply those business rules to detect cases of potential fraud and abuse, a Data Warehouse where that data is structured for querying, BI models (one ESSBASE cube and four OBIEE models) and dashboards/reports.
Result
- Insertion and update of around 300,000 records/day.
- Approximately 40 processes analyzed.
- Around 30 reports made available.
- 8 people involved (IT Department, Technical Department and Gstep).
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