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Romania

We’ve been given a dataset for 2 months period of medical services reimbursed by one of the big Health Insurers.

Business case

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Outcome 1
We found 8% of suspicious services with a different probability rate. 3.5% are highly probable to dispute
0,0%
0,0%
0,0%
0,0%
0,5%
2,4%
0,3%
0,4%
0,1%
1,5%
0,2%
1,5%
0,2%
0,0%
0,2%
0,0%
0,2%
2,1%
5,4%
5,9%
4,6%
Clinic 7
Clinic 6
Clinic 5
0,0%
0,0%
1,4%
0,0%
0,0%
4,0%
15,9%
Clinic 4
0,0%
3,3%
2,1%
0,0%
0,5%
0,8%
8,2%
Clinic 3
0,0%
0,0%
0,0%
0,5%
0,0%
7,6%
17,2%
Clinic 2
0,3%
0,0%
0,0%
1,0%
1,1%
1,6%
6,6%
Clinic 1
Radiology
Dermatologist services
Otolaryngologist services
Gynecologist services
Ultrasound examination
Biochemical tests
Laboratory services, General
% of suspicious services
Medical partner
Outcome 2
Service name classification, medical case aggregation, identification complex patterns of fraud.
Advanced health analytics for further management decisions
1,1%
1,8%
1,2%
9,5%
0,6%
8,3%
2,0%

3,5

3,5

%

High probability to dispute

8,4

8,4

%

Suspicious services

3,5%
4 669
233 623
High probability
3,5%
5 472
239 162
Medium probability
1,4%
1 2016
91 521
Low probability
8,4%
11 357
564 307
Fraud detected
100%
101 144
6 742 086
Total Claims
% in claims
# of services
Claims, €
Category
Medical partner
Clinic 7
Clinic 6
Clinic 5
Clinic 4
Clinic 3
Clinic 2
Clinic 1
% of suspicious services