Medical Insurance Risk Control
AsiaInfo Data’s intelligent risk control operation service for health insurance fund combines AI with big data tools, collects and learns data from tens of thousands of fraud cases and multi-dimensional comparison data, searches for the law of fraudulent behavior patterns, addresses various new types of violations that keep cropping up, and exerts a forceful deterrent to various types of fund frauds, wastes, abuses and other irregularities, to help the government crack down on fraud and insurance frauds; regularly identifies high-risk behaviors/events that may affect fund operation, and helps health insurance departments to resolve potential risks in a timely manner through intervention and management measures in ex-ante and ex-post stages, so as to effectively control unreasonable expenditures of health insurance funds while ensuring the quality of medical services, improve the use efficiency of health insurance funds, and alleviate the pressure on local finances.
Finances at all levels bear most of the financing pressure on urban and rural residents’ health insurance funds
In recent years, as the economy enters a new normal and the problem of an ageing population comes to the fore, China is facing rapid growth in the expenditures of medical insurance funds and increasing pressure on finances at all levels. In addition, the rampant emergence of excessive medical treatment and insurance fraud has posed a huge challenge to the sustainable development of health insurance funds.
The annual average increase in national accumulated financial expenditure on health care is 11.7%
11.7%
The national budget for health care accounts for approximately 7.2% of national fiscal expenditure
7.2%
Total recovered medical insurance fund in the 2022 special campaign
RMB 18.8 billion
The effectiveness of medical insurance fund supervision needs to be improved urgently
Various ways of insurance fraud, high expectations
One million medical institutions at all levels, 11.75 million health workers, 1.3 billion insured people, trillions of yuan...
False hospitalization, hospitalization medical examination, proxy swipe of medical insurance card, duplicate medical registration, and other forms of insurance fraud...
The public has high expectations of health insurance, and there is still room for improvement in deductible line, reimbursement rate, and comprehensive arrangement for serious disease...
Staff shortage, slow upgrading, and low-level of regulatory systems
The National Healthcare Security Administration was established in 2018 with a staff size of 80 people, and healthcare bureaus at all levels have been established one after another, with a low staff size...
The regulatory procedures and rules are relatively rigid, the escalation mechanism is not yet perfect, and the escalation is slow and the cycle is long...
The regulatory system for violations is at a low level, and the system focuses more on building than on effectiveness...
As the expenditure of medical insurance funds continues to grow at a high rate, finances at all levels bear most of the financing pressure on urban and rural residents’ health insurance funds There are huge challenges to sustainability, with studies showing that unreasonable expenditures account for about 35% of health insurance fund expenditures.
AsiaInfo’s intelligent risk control operation services for health insurance can help the government speed up the realization of free basic healthcare for all.
The intelligent risk control operation services for health insurance combines AI with big data tools to effectively control unreasonable expenditures of medical insurance funds, improve their use efficiency, and alleviate the pressure on local finances.
Accurately identifying cases of non-compliance
Oriented towards enforceable results, the service can identify various violations and irregularities in the use of health insurance funds and reduce the workload of health insurance departments.
Specialist consultancy services for health insurance audit
AsiaInfo’s health insurance experts provide on-site consultancy, case clue analysis and Q&A services according to the needs of the health insurance sector.
Exante and ex post reminders
Based on regulatory needs, supervision can be moved forward to the ex-ante and ongoing stages, and timely intervention can be made on risks in fund utilization by means of reminders and interception.
Fund operation risk exposure perception service
The service can fully gather heterogeneous data from population health, medical care, medical insurance settlement and other sources to analyze the operation trend of funds in real time, assisting users to make fund supervision more targeted and resolve all kinds of fund expenditure risks in a timely manner.
Monitoring and identifying new types of fraud and misuse of funds
New intelligent identification engine for violation risk can combine heterogeneous data from multiple sources, such as population health, medical care, and health insurance settlement, with AI technology, to identify various types of new irregularities.
Fund operational risk assessment and advisory services
AsiaInfo’s data operation team consists of health insurance fund professionals with rich experience and top experts in health insurance research, providing users with complete assessments and consulting services on fund operation, which enables users to assess local health insurance policies and norms, administrative policies and norms, actual fund expenditures, and local regulatory measures...
Core Competitiveness
The intelligent risk control operation services for health insurance combines AI with big data tools to effectively control unreasonable expenditures of medical insurance funds, improve their use efficiency, and alleviate the pressure on local finances.
-
AI Intelligent Platform
Based on the calculation of rapidly acquired massive unstructured data at the national, provincial and municipal levels, AI intelligence adaptive learning problem funding, analysis of early warning and appraisal indicators, we can develop a specialized model identification capability.
-
BI Audit Platform
Our in-house multi-dimensional macro data analysis perspective enables multiplied efficiency for regular problem judgments to address the limitations of micro perspectives.
-
Code Translation Platform
For the code recognition problems of massive medical systems and health insurance rules, we offer plug-and-play automatic identification capability with an accuracy up to 95%.
-
Data Foundation Medical Database
Our four basic medical dictionaries and databases, which have been developed over years, provide more accurate and intelligent identification capabilities, becoming a core and distinctive capability.
-
SaaS System Operation Capability
For the at least 120 work steps required to verify each questionable fund, we achieve standardized and intelligent cloud service capabilities, and solve the contradiction between process standardization and data localization through a localized work model of local government cloud.
-
Paths:
Step 1: Official signing of agreement
The two parties sign a framework agreement, with zero input from the local government in the early stages; AsiaInfo enters the scene to prepare for service delivery.
Step 2: Platforms aggregate data
Based on the available city platforms or assistance for building a regional medical big data platform, we can aggregate all the data related to medical insurance auditing in the region. Providing free validation testing and issuing reports based on the situation.
Step 3: Full launch of services
The two sides sign a supplementary agreement on services, specifying cooperation mode and result-based service fee-charging and no charge for no effect; at the same time, AsiaInfo launches a multi-dimensional and intelligent risk-control probing engine to conduct a comprehensive audit and monitoring, and generates an analysis report.
Step 4: Outcome-based pricing
Based on the results of the comprehensive audit, we will cooperate with the regulatory authorities in irregularity disposal and result tracking, and evaluate the effectiveness of use, and settle the service fees only after results are produced.
Success Stories—Crackdown on insurance fraud of all kinds
In the special campaign against insurance fraud of X City, AsiaInfo assisted the city to conduct special regulation on 20 selected medical institutions for their suspected practices of insurance fraud in the current year, and found that a number of hospitals were suspected of high-risk practices of fraudulent use of health insurance funds in nine major categories. Various suspected clues of irregularities were found, involving an overall amount of RMB 82,923,100 and a total of 32,826 people.
-
Induced hospitalization
RMB 8,253,300 -
Overlapped hospitalization
RMB 6,871,500 -
Frequent hospitalization
RMB 31,777,500 -
Examination package
RMB 28,682,500 -
Indication-based hospitalization
RMB 5,243,600
-
Hospitalization for health check-up
RMB 1,296,500 -
Similar medical costs
RMB 663,000 -
Hospitalization in pairs
RMB 716,600 -
Post-mortem visit
RMB 8,700 -
......
Success Stories—item exchange, overlapped hospitalization for insurance fraud
Item exchange of grass-root medical organization X in the year X
Hospital X replaced the actually conducted program of “blood photo-quantum autologous blood transfusion therapy and disposable transfusion device” with the program of “blood thinning therapy and autologous blood transfusion” in the medical insurance catalog.
16,415 times of replacement regarding the two items
A total of RMB 1.035 million was illegally obtained
False hospitalization of hospital X
In the ophthalmic department of a hospital, the number of admissions was often greater than the number of beds available, and at certain times the number of admissions exceeded the number of beds by more than four times, suspected of overlapped hospitalization totaling 202 bed/day.
As the expenditure of medical insurance funds continues to grow at a high rate, finances at all levels bear most of the financing pressure on urban and rural residents’ health insurance funds There are huge challenges to sustainability, with studies showing that unreasonable expenditures account for about 35% of health insurance fund expenditures.
UNIQUE VALUE
AsiaInfo Data's unique value lies in its use of full-stack big data products and AI platform, it is capable of providing the government, enterprises, and research institutes with sufficient AI computing power resources, big data analysis models, and in-depth innovative solutions.
