The insurance industry suffers billions of dollars in damages annually due to unwarranted benefit payments. Payments for fraudulent claims by health insurers account for more than half of this. While the vast majority of service providers bill correctly, we pursue and prosecute the few cases of fraud that continue to occur. Because it is honest premium payers who ultimately bear the cost when service providers submit false or inflated bills.
Transparency against insurance fraud
Helsana employs about a dozen people to investigate, prosecute, detect and recover fraud offences. 136 cases were successfully closed in 2020, resulting in around CHF 9.6 million in benefit payments being returned to Helsana. A further 161 new cases were opened in that same period.
The digitalisation of data management plays an increasingly important role here. Retrospective data analysis is now fully automated and compares service settlements with millions of similar settlements. It detects conspicuous patterns and outliers that need looking at more closely. Each detected case is fed back into the artificial intelligence deployed for data analysis, to help it learn.
Data-based analyses lead to the discovery of irregularities in around half of cases. These irregularities are meticulously traced and retraced. Among the other half of possible offences, tips from whistleblowers, spot checks in the day-to-day business, or even media reports, result in investigations being opened. In this way, the function makes an ongoing contribution to fair prices in the Swiss health system – and therefore to premiums remaining as stable as possible.