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This November, at the NHCAA (National Healthcare Anti-Fraud Association) annual conference our partner CGI showcased their Azure based solution CGI ProperPay. It’s always exciting to see a new solution that truly challenges how we address current healthcare processes and costly problem areas, particularly when the financial loss associated with that process is well known and well quantified. Such is the case with healthcare claims fraud, waste, and abuse.
Without going into a detailed statistical analysis we should note that in their report, “The Financial Costs of Healthcare Fraud 2014“, Jim Gee and Professor Mark Button found that the average global healthcare loss rate due to fraud is about 6.99% or approximately $487 billion (€413 billion) with some organizations reporting a loss of 15% or more. NHCAA has estimated the US health-care industry’s cost of fraud at more than $60 billion.
So, needless to say there is plenty of room for improvement, but that improvement must be supported by solutions that digitally transform historical “pay and chase” approaches to solving the problem of healthcare claims fraud, waste, and abuse. New solutions must leverage modern technology, be data driven, and meet (or exceed) the healthcare industry’s security, privacy, and compliance requirements. These modern solutions must also pro-actively address the problem before it happens. This is the approach that CGI has taken with the CGI ProperPay solution. As shown in the table below, CGI’s customers expressed the need to harness the power of analytics to improve care and reduce costs while also optimizing operations to drive transformation. And they also needed this to be cybersecure and “cyber-private” in order to enable collaboration both inside and outside the enterprise.
This is why CGI developed their solution on the Microsoft Azure cloud computing platform. Microsoft Azure is secure, private, and compliant by design. Azure today complies with over 62 global regulatory frameworks, meets and exceeds the HIPAA and HITRUST requirements and will support our global customers’ General Data Protection Regulations mandates. Azure provides the artificial intelligence and analytics capabilities needed to digitally transform healthcare claims fraud, waste, and abuse processes into data-driven proactive solutions that leverage the expansive and scalable power of the cloud to minimize the costs of fraudulent claims. In fact, CGI’s solution is being used by a large federal agency to identify and recover improper payments (overpayments/ underpayments) across a population of 8.5 million insured individuals. CGI imported and analyzed millions of claims data across 229,400 providers and 1,177 hospitals through the ProperPay system. Using the powerful data analytic capabilities of ProperPay CGI identified potential types of claims or services for recovery auditing enabling the identification and recovery of $1.9B improper payments to date.
This is just one of the great stories where this solution is working. Try the preview solution today on the Microsoft AppSource platform. More information on Microsoft’s artificial intelligence products and solutions can be found here. Please feel free to contact me or Rob Rolf if you’d like more information about the CGI ProperPay solution.