Case Study: Mediclaim Outlier Detection at TTK Healthcare TPA
The "Mediclaim Outlier Detection Engine" - MODE - designed by Quintes and developed by WebEdge and implemented at TTK Healthcare TPA Pvt Ltd is the most innovative and only one of its kind solution that exists in the health insurance industry in India.
Built with highly user friendly interfaces and a powerful Oracle 10g backend, MODE analyses every claim with a robust Outlier Detection Engine that points out "unusual health insurance claims" based on key parameters such as age, length of stay, claim amount, etc.
Even more interestingly, any number of new parameters for outlier detection can be added easily - so fine tuning the application to make it better and more stringent is all possible with little or no development effort.
A by product of the implementation of MODE at TTK is the remarkable ease with which the application can be used for data cleansing. This has particularly helped TTK in maintaining a high quality of data apart from making their executives more accountable for their performance.
The application can be used to prevent frauds in health insurance claims. It can also be extended to detect outliers and frauds in any type of insurance or medical reimbursement claims.