Fraud is a major concern

In Canada, between $1.2 billion and $6 billion are lost by employers who sponsor benefits plans. Insurers spend millions to recover that money without significant success compared to this magnitude.

" Estimates put fraud representing as high as 10 % of health care spending in Canada "

Fighting fraud doesn't help sponsors to recover their money. It keeps their premiums high not only because of the money lost, but also because of the additional processes incured by insurers. Everybody loses unless fraud is impossible such as with SITL.

SITL offers a system that allows to reimburse members and health care providers in real time, at the point of service.

Smart phones, high speed cell networks and artificial intelligence, to name a few, are part of consumers everyday life. Still, insurance providers don't take advantage of all this available technology to leverage their profitability and efficiency.

Think about this: consumers can get purchases from accross the country delivered to their door faster than they can get reimbursed for some of their professional health care.

What if you could detect fraud before it happens?

Detecting fraud after it happened is the traditional way of fighting fraud. In fact, there has been no other way to do it since insurance exists. Recently, adding artificial intelligence to the process helps, but a fact remains: the money is already gone. Efforts and additional money are required to prosecute fraudsters and to get the money back. It's obvious that this additional money is lost to the fraud.

Imagine now, instead, using artificial intelligence to recognise claim patterns at the time the claim is submitted. If a fraud pattern is detected, the claim is automatically rejected before it happens.

Fraud Patterns

When it comes to fraud, fraudsters are creative. Here are only a few of the fraud patterns used by members and practitioners. Unfortunately, there are other patterns.

The face of fraud

Fake Receipts

Plan member submits fake claims for services or drugs they never received by making fake receipts. Sometimes, the service provider and the plan member team toguether and split the claim proceeds. In that case, it is the service professional who provides a false receipt.

By combining the location of two devices at the point of service at the same time, MediCoupons ensures claims are legit. It is extremely difficult, if not impossible, to reproduce these conditions to make fraud profitable to fraudsters.

The face of fraud

Collusion Rings

Collusion rings are an organised way to profit from fraud. In that case, a service provider manage to regularly provide false receipts to a group of members and split the proceeds with them.

Paper claims are often times used in that scheme.

For all types of claims, without exception, the claim request is automatically and instantly sent, analysed and settled by SITL. Reimbursement is immediately deposited into the professional account and the client pays the remaining amount.

The face of fraud

Misrepresentation

In that fraud scheme, service providers falsify dates, locations, and service details on receipts. For example, dentists may overseparate dental codes so that the amount of the claim is inscreased or multidisciplinary health centers that offer a wide range of services exploit multiple health benefits at once.

Imagine a coupon booklet that would be printed and sent to members. If a member has 10 physiotherapist coupons, then, he is covered for 10 visits. If his booklet doesn't contain physiotherapist coupons, then he doesn't have that coverage.

SITL provides MediCoupons, a mobile app that is simply the mobile version of this coupon booklet.

The face of fraud

Fake Practitioner Identity

Fraudsters submit false claims under the name of a practitioner who ignores it's identity is counterfeited. Not only this is a problem from the fraud perspective but the reputation of the practitioner is also compromised.

Abuse - Another sort of fraud

Benefits are meant to financially back you up in case expenses are required because of a health condition. But sometimes, members use them like if it was free money. Getting services not required is another way to fraud.

The face of fraud

Abusing

Some members abuse of the system by claiming for unnecessary services. For instance, they will claim massages or acupuncture sessions not related to their health condition or they will increase the sessions towards the end of the year to use their coverage as much as possible. This technic is hard to detect but do as much harm to the sponsor fees.

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