Mumbai: SAS has partnered with India’s National Health Authority (NHA) to use data analytics for fraud detection and prevention.
SAS will enable data analytics for NHA’s National Anti-Fraud Unit (NAFU) to help monitor fraud and abuse arising anywhere in the implementation structure of the scheme, the company said in a statement.
NHA is a top government body implementing India’s flagship public health insurance/assurance scheme Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY).
Ayushman Bharat PM-JAY is the world’s largest government-supported health assurance scheme that provides a health cover of Rs.5 lakh per family per year to cover secondary and tertiary care hospitalization to over 10.74 crore poor and vulnerable families across India.
So far, nearly 95 lakh treatments worth more than Rs. 12,882 crore have been provided across 19,000 hospitals in 32 States and Union Territories.
Through NHA’s Fraud Analytics Control and Tracking System (FACTS), SAS will also support the prevention and detection of fraud through a healthcare-specific fraud and abuse data model that consolidates data from internal and external sources including claims systems, third parties as well as unstructured text.
SAS will contribute to the NHA’s overall objective of detecting and minimizing healthcare fraud using advanced analytics.
“After a six month-long proof of concept exercise where five top global analytics firms participated, we are pleased to select and have SAS support us in analyzing one of the largest disparate data sets pertaining to health care administration through a central platform,” said Dr. Indu Bhushan, CEO – National Health Authority.
“We will employ advanced data analytics to all the claims we are processing as well as administering to identify anomalies and detect and prevent fraud and abuse from occurring across the board,” added Dr. Bhushan.
Leveraging data analytics according to Dr. Bhushan will enable Ayushman Bharat PM-JAY to further strengthen its service delivery to more than 50 crore poorest citizens and empower them with quality secondary and tertiary health care.
“Providing health care access to poor and vulnerable families across India is complex process. But data backed with analytics, can ascertain a holistic view. NHA’s FACTS project is aimed at detecting and minimizing health care fraud using advanced analytics,” said Noshin Kagalwalla, VP & Managing Director – SAS India.
“With SAS software, we have provided a framework of support to not just detect & prevent fraudulent claims but also provide a broader view of patients being served under the PM-JAY scheme,” added Kagalwalla.
SAS will provide end-to-end framework for ensuring claim processing with specific components for fraud detection, alert management and case handling for NHA.
SAS’ fraud analytics engine enabled for NHA’s FACTS uses multiple techniques such as automated business rules, outlier analysis, predictive modeling, text mining, database searches, exception reporting and network link analysis to uncover the likelihood of a health insurance scheme fraud that benefits over 10.74 crore families living in poverty.
Furthermore, the analytics engine is enabled to use advanced analytics with embedded artificial intelligence (AI) and machine learning algorithms to prevent and detect fraud across India for the ambitious scheme.