Metropolitan Health Group (MHG), the healthcare business of New Africa Capital (NAC), is now using the latest business intelligence (BI) tools to pick out suspicious patterns in medical practitioners' and pharmacists' claims.
The group, which administers some 16 medical aid schemes and offers a franchise solution to two schemes, is using a Cognos PowerPlay Web solution to analyse the volumes of data generated daily in the form of medical claims.
"The Cognos PowerPlay software works hand-in-hand with our 60GB data warehouse and profiling system, which the clinical audit department uses to review practitioners' claiming patterns," says Miranda Vineall, data warehouse manager responsible for BI at MHG. "Suspicious patterns can be easily picked up from the data cubes created in PowerPlay and then further analysed by auditors who can then drill down using Impromptu and SQL queries to analyse specific transactions, should they need closer inspection."
Although BI is delivering significant business benefits in helping to control claims fraud, the system was initially implemented to help MHG streamline and enhance its reporting capability to its customers, the medical aid schemes. In particular, the group wanted to be able to readily produce high-level summary reports for use at the individual medical aid scheme, board of trustee meetings. These reports are aimed at highlighting benefit expenditure trends and tracking MHG's performance against its service level agreement (SLA) with each medical aid scheme.
To this latter end, the company has also recently bought Cognos' Key Performance Indicator (KPI) Business Pack which gives managers a view of how the company's performance compares with each SLA. This is made possible, at a glance of their desktop PCs, using a simple 'traffic light' indicator, per performance measure.
"With KPIs they only need to check on areas highlighted as potential concerns, instead of having to study all the available reports," says Andrew Connold, managing director of Synergy Computing, the BI specialist which supplied the MHG solution and currently provides the technical and training support.
"As a medical aid administrator, the analysis and KPI reports have become a critical, yet easy-to-use management tool. They enable managers and staff to readily and pro-actively identify service level concerns, which management can then address, before they become a significant problem, or penalties kick in. This is a key business benefit."
Before the implementation of the Cognos solutions, MHG managers relied on manual manipulation of data using Microsoft Access and Excel spreadsheets. These required considerable time and effort in extracting and manipulating data from the relevant sources, with a high risk of human error potentially affecting the result. With the Cognos implementation, this process has been automated, resulting in significant time savings and increased accuracy.
Another of MHG's major objectives in using BI tools was to eliminate the pressure that the generation of ad hoc reports put on its specialist BI team. With the implementation of the Cognos solution, standard detailed reports are now automatically generated using Cognos Impromptu and sent directly to users.
"The result is that the demand for ad hoc summary reports dropped dramatically and even more so following the introduction of the PowerPlay Web solutions," says Vineall. "Currently, Impromptu is used only by power users, resulting in some ongoing demand for ad hoc reporting, however, this is now being addressed."
As a company committed to operating within a paperless environment, MHG has begun to distribute standard reports electronically and e-mail detailed analyses requested by clients. The next step is to utilise PowerPlay's Web-enablement capabilities to provide clients with direct Web access to the published data cubes. This facility is being rolled out over the next year and is already live for one client.
Following on from this greater information access, is a plan to provide users with their own report extraction facilities. The company is currently working on developing applications to run off its data warehouse, which comprises data from its core administration databases, as well as data from its call centre environment.
"These will enable users to extract detailed standard reports on demand, instead of going through a request process, or only receiving reports on a scheduled weekly, or monthly, basis. It will also give the BI team more time to focus on other development work to further meet the information needs of the business," says Vineall.
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