From over medication to fraud, Green Crescent CEO Carlos J Sardegna talks about the region’s health insurance business heating up.
March 24, 2011 3:05 by shafeer
Before we authorise patient care, we preview them for medical necessity and to see it that the procedure is appropriate for the diagnosis. When the patient is in the hospital, we also visit them to ensure that they get all the appropriate care and take a look at what exactly being prescribed, for medical necessity point of view.
It is not an attempt to deny care, but to see to it that no fraud is taking place. And finally, we go back after the case on a random basis.
Q: Where does technology come into play?
There are now software packages available, which can look at the claims and see that the procedures are appropriate for the diagnosis. The frequency of claims per member is somewhere between four and five. So, with 100,000 members, the total number of claims is up to 500,000. We are now looking at the implementation of software packages which will identify anomalies in payment. Whenever we find frauds we pursue it vigorously. We have provided information to check doctors. We have got payments back from doctors.