Artificial Intelligence powered risk classification system for detection of waste, abuse and fraud in healthcare insurance claims tailored for GCC region

2. I am Kiril Milev
Managing Director of Netcetera Middle East
kiril.milev@netcetera.com
Hello!

3. Innovation Data BenefitsStandardization

4. 10%lost in waste, abuse and fraud

5. The Concept
RiSICclaims tagged claims
reporting
configuration

6. The Concept
RiSICclaims prediction
outcome
training
feedback

8. “No consultations, high number of labs esp. influenza,
CULTURE AEROBIC IDENTIFY. Billing of many CPTs under his
name by many different providers”
“Nephrologist doing unrelated labs like chest xray, ecg for usg, rft
for hypertension and medicine is only antihypertensive”
“GP billing for specialist, injections given with no bill for drugs,
over prescription of risek, multivits for acute urti”
“Overbilling of CPTs, the number of CPTs is inconsistent with the
number visits, Upcoding of ICDs”.
“Pediatric in <provider>, billing for consultant code NN when he is
specialist, over investigation with viral tests, TSH, with no
relevant medication given”
Real WAF cases detected by RiSIC
“Over investigation with eye ultrasound even in case
conjunctivitis, chalazion and dry eye”.
“Pediatric consulting adults and billing specialist fee”

9. Results
RiSIC adds 69% more savings which
increases the denial rate from 5% to 8.4%
RiSIC identifies 80% of
the existing denials

10. Kiril Milev
kiril.milev@netcetera.com
+971 50 903 8552
Thanks!