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VZP to implement anti-fraud software

New program flags possible abuses of insurance claims

By Claire Compton
Staff Writer, The Prague Post
September 17th, 2008 issue

A new software program that helps detect insurance fraud has already been put to good use for Czech National Health Insurance (ČNZP), but it promises to catch even more cases as the country’s largest healthcare provider, VZP, plans to implement the program in the next couple of years as part of their plans for modernization.
ČNZP has used the program to monitor records on its 213,000 clients, some of which date back 14 years. The software runs through auditing records and provider claims looking for patterns that may indicate fraud where employees might not catch it. Of 20 million claimed services last year, 214,000 cases were flagged as suspicious. After eliminating minor payments, 14,000 cases remained highly suspicious. In more than half of those cases, auditors agreed with the program that there was evidence of insurance fraud, said Vladimír Solc, director of the ČNZP project department.
The scope of cases would be even greater when applied to VZP’s records, as the company has 6.5 million clients.
Rod was careful to say the majority of instances where information is missing or falsified are not technically insurance fraud, a legal term, but instead classified by the provider as unauthorized statement of medical care.
“That means there is no evidence that the medical care was executed in the patient’s medical documents, or that it was registered under a different patient,” Rod said.
VZP simply refuses payment for such unauthorized cases, but it only becomes fraud when the court labels it as such in a lawsuit. While most cases are discovered to be administrative mistakes, any deliberate activity is met with contract termination rather than prosecution.
“When it happens repeatedly, we’ll go as far as to terminate the contract.”
The software often works best when it finds suspicious activity where employees wouldn’t think to look, ČNZP analyst Milena Šolcová told the daily Mladá fronta Dnes Sept. 9.
“It has found, for instance, two doctors who reported the treatment of one and the same patient, which cost very large sums of money. Without the artificial intelligence, we would never have checked these particular doctors,” she said.

Claire Compton can be reached at ccompton@praguepost.com


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