The Power of Combining Big Data Analytics with …

1 1 2013 CGI GROUP INC. WHITE PAPER The Power of Combining Big Data Analytics with Business Process Workflow In this paper, we demonstrate how the combination of big data Analytics , business process workflow and smart people with the right skills can deliver sustained and measurable success. This can be achieved in many different industries. We take as our example the health care payments sector, where nearly $3 trillion dollars in payments flow from health insurers to providers every year in the alone.

2 While most of these are straightforward reimbursements for agreed upon services, a proportion should not have been paid in the first place and need to be recovered. Having a partner act as an intermediary to audit and recover these improper payments has many advantages. A crucial advantage is that the business process service (BPS) partner is also in an ideal position to harness big data Analytics to produce improvements in recovery rates for typical improper payments cases as well as instances of outright fraud while minimizing the impact of audits on providers.

3 2 TABLE OF CONTENTS introduction .. 3 AUDIT SERVICES IN HEALTH CARE .. 3 THE AUDIT PROCESS .. 3 THE Power OF Analytics .. 5 THE FUTURE .. 8 CONCLUSION .. 10 3 The truth is that many organizations are already successfully harnessing the Power of big data. introduction Big data is a hot topic across executive suites today. The amount of data that is available to businesses is increasing exponentially, with social media and machine-to-machine as just two of the leading sources. Storage is getting cheaper, driven by cloud computing, and processing Power is getting faster.

4 How is all of this big data being structured and analyzed to deliver real business benefits? What are these tangible, measurable benefits? The truth is that many organizations are already successfully harnessing the Power of big data. It s best done where innovation is always done best in the context of a real business problem to fix, with smart people who can structure the necessary data logic and interpret its results, and a business process workflow that turns these results into desired business outcomes.

5 In this white paper, we take an in-depth look at the impact of Combining smart people, big data Analytics and business process workflow in one particular market sector the auditing and recovery of improper health care payments by insurers to providers. If you work in the health payment sector today, you will find insights that will directly impact your business. If you are in a different industry, we believe you will find the health payment example relevant for understanding how the combination of smart people, big data Analytics and business process workflow could translate into cost-effective solutions for your own organization.

6 Audit services in health care Health care is delivered in the and many other countries under variations of the same model, despite the complexity that can sometimes be apparent. An individual enrolls in a health care plan (which may be a government sponsored or private plan), visits physicians and other care providers, and perhaps has a hospital stay and takes medications. The physicians, the hospital and the pharmacy are all providers of services and make claims on the health care plan for payment.

7 This is happening across the world, millions of times a day. About $3 trillion in payments flows from health insurers to providers each year in the alone. By any measure, it s big business. While most of it is proper and accurate, the hard truth is that inaccurate, improper and sometimes fraudulent claims are made. Let s assume, for example, we have a claim for a physician s appointment. The claim form says the visit lasted one hour. How can this be verified? What other data might be available to check that the claim is truthful?

8 Let s take another example: two claims, filed one after the other, for the same patient to have an appendix removed. It s easy to spot the impossibility here, making this a clear cut case of an improper claim. As a final example, take the case of a medical group in a small town whose claims come mostly from patients with addresses far away from the town much farther than is typical for similar providers. Does this group offer excellent services that explain the long trips to visit its doctors, or is something else going on?

9 In the , many health care plans both public and private engage specialized auditors to review claims, find improper ones, and either prevent a payment before it takes place or recover a payment that has already been made. The audit process When a claim is made, there are typically two stages involved in processing the necessary data, especially in the case of a government sponsored plan. The physician will write the 4 Taken together, the information sources used in auditing and researching claims amount to big data indeed.

10 Business process workflow is essential to turning analysis into action. medical records, and a coder will review those records and apply the appropriate code to the claim. The claim is then routed to the health care plan for payment. A health care plan will typically audit a sample of claims to identify any that are improper, either on its own or through a third party specialist. CGI is one such third party auditor, working on behalf of a range of health care plans in the public and private sectors.