Global Overtreatment
TCS client* full scope launch of medical business processing: claims management and pre-authorization control
*Leader TPA of KSA market
5 pilots in 3 regions were made:
KSA
UAE
Bahrain
Raise of engine decisions quality
92%
96%
from
to
unique ICD-10 codes were updated for actual local and international clinical guidelines
>300
Business agreement signed with 6 new clients in 4 regions:
KSA
UAE
Bahrain
Mexico
detected overtreatment level *
28%
*previous rate for the full 2023 year was 27%
of all KSA Market claims & pre-auth requests checks monthly via Mains Lab engine
15%
Integration of new KSA
SBS v2
nomenclature was done
Business agreement signed with 6 new clients in 4 regions
KSA
UAE
Bahrain
Mexico
TCS client* full scope launch of medical business processing: claims management and pre-authorization control
*Leader TPA of KSA market
Raise of engine decisions quality
92%
96%
from
to
detected overtreatment level *
28%
*previous rate for the full 2023 year was 27%
unique ICD-10 codes were updated for actual local and international clinical guidelines
>300
of all KSA Market claims & pre-auth requests checks monthly via Mains Lab engine
15%
Integration of new KSA
SBS v2
nomenclature was done
5 pilots in 3 regions were made:
KSA
UAE
Bahrain
Overtreatment Russia
has been developed and implemented
Module for Inpatient medical cases processing
has been developed and implemented
Separate API service for linking a letter of guarantee to medical services from an invoice
unique ICD-10 codes were added and updated for actual local clinical guidelines
>900
of all Russia VHI Market claims checks monthly via Mains Lab engine
80%
Insurance Companies out of the TOP-10 in Russia use the Mains Lab product
6
has been added:
1) the level of persuasiveness of recommendations
3) the frequency of service provision
2) the level of reliability of evidence
The ability to take into account additional parameters of regulatory acts
User Support Portal
has been launched for prompt communication to ensure high-quality service operation
Mains Lab solution found
200
million rubles
of defects, having processed invoices for
5,0
billion rubles
The ability to check provided medical services
taking into account the insurance program coverage according to the policy mask has been added
Insurance Companies out of the TOP-10 in Russia use the Mains Lab product
6
of all Russia VHI Market claims checks monthly via Mains Lab engine
80%
Mains Lab solution found
200
million rubles
of defects, having processed invoices for
5,0
billion rubles
unique ICD-10 codes were added and updated for actual local clinical guidelines
>900
has been developed and implemented
Module for Inpatient medical cases processing
User Support Portal
has been launched for prompt communication to ensure high-quality service operation
has been added
1) the level of persuasiveness of recommendations
2) the level of reliability of evidence
3) the frequency of service provision
The ability to take into account additional parameters of regulatory acts
The ability to check provided medical services
taking into account the insurance program coverage according to the policy mask has been added
has been developed and implemented
Separate API service for linking a letter of guarantee to medical services from an invoice
Fraud, Waste, and Abuse Russia
Project for systematic counteraction of fraud and abuse
4
in
insurance companies from the TOP-10 list was launched
was developed and tested
Module for detecting the blurring of the average check
Round table on the topic of detection and counteraction of fraud in voluntary health insurance was held with the participation of experts
8
insurance companies
from
was developed and tested
Module for detecting the addition of ICD diagnosis codes
The solution was used to detect VHI fraud and abuse in the amount of
>100
million rubles
Global
Fraud, Waste, and Abuse
Conducted 5 pilots with Insurance Companies and TPA's from 3 regions:
KSA
UAE
Bahrain
Complete FWA investigation of 1.5 year claims database has been made for a client of TOP-10 list in KSA. Results were successfully used in provider negotiation process
New modules were implemented:
1) detection of doctor's abnormal behavior
2) detection of collusion between policyholder and doctor
Business agreement signed with
2
clients in KSA and
1
client in Bahrain
Solution “Second”: Russia
was developed and launched: calculation of cost estimation and preparation of repair orders
New solution for settling insurance cases under CASCO
Insurance Companies out of the TOP-10 in Russia use the Mains Lab product
6
Number of urgent requests increased by
40%
9000
are checked every month
requests
up to
Signed contracts with 2 clients:
Soglasie
Alfa Insurance
Started developing and implementing of an assessment for Chinese cars:
>20
popular brands
the update will include
Underwriting Russia
Function for automated information collection about the insurer's office addresses through open sources
has been developed
Pre-training of forecasting models on new data has been carried out to maintain a high level of accuracy
The solution processed
>500
VHI tenders of large corporate clients for a total of
>10
billion rubles
Global Underwriting
The product was presented at two InsureTek conferences to over
500
attendees from the insurance industry in 2 regions:
KSA
UAE
1000
SME (small and medium) health policies
was developed and tested
The solution for renewal price calculation
on
3) AI model for forecasting hospital payments
have been developed and integrated:
2) maternity model
New models
1) detection of chronic patients
Business agreement signed
2
clients in KSA
with
Pilot projects for
3
MENA Insurance Companies have been completed successfully