New Payment Integrity Platform Launched to Cut Healthcare Fraud in South Africa

JOHANNESBURG, Aug. 20, 2015 /PRNewswire/ --

Highlights:

• 10-20 percent of paid healthcare insurance claims estimated to be fraud, waste or abuse
• FICO and AfroCentric Health's Helios IT partner to launch South African healthcare insurance fraud, waste and abuse solution and drive down losses
• Adaptive predictive analytics in new solution detect abnormalities at the claim, provider and procedure level

The AfroCentric Health Group (AfroCentric) and global analytics software firm FICO today announced a strategic partnership that establishes the South African healthcare industry's leading fraud management solution. AfroCentric's healthcare IT services subsidiary, Helios IT Solutions (Helios ITS), and FICO now offer this fraud management and payment integrity platform to all medical schemes in South Africa.

FICO^® Insurance Fraud Manager uses adaptive predictive analytic models that are integrated within purpose-built software, giving medical schemes (payers) a vastly enhanced ability to identify and address existing and emerging losses from fraud, waste and abuse. Medical schemes can use this solution, deployed through Helios ITS' secure technological offering, to detect, review and investigate suspicious claims, members and providers, and deliver cost-effective quality care with integrity.

"Healthcare fraud is on the rise, accounting for between 10 and 20 percent of gross healthcare claim payments globally according to KPMG," said Paul Midlane, AfroCentric's general manager of Legal Governance and Risk Compliance. "Based upon World Health Organization estimates that South Africa spent R376 billion on healthcare in 2011 alone, substantial losses are occurring within an industry already plagued with rising costs. It is time to ensure the integrity of the South African healthcare system – not only to stem losses, but also to improve the access, cost and quality of care for the people of South Africa."

The cutting-edge fraud detection system employs predictive analytics to detect and reduce fraud, waste and abuse at the claim, provider and procedure levels. Importantly, the solution enables schemes to augment their existing payment integrity capabilities.

Said Helios ITS Managing Director Vijay Pillay: "Finding a solution to counter healthcare fraud effectively in South Africa has been regarded by many in the industry as the silver bullet for decades. After extensive examination of FICO's Insurance Fraud Manager solution, we are really excited about the benefits and impact we anticipate by enabling schemes to reduce these losses and free up massive resources for better patient care. This partnership with FICO demonstrates a meaningful stride towards solving an industry-wide scourge of financial loss."

"We've worked with healthcare insurers for decades, and our analytic approach has proven itself time and again," said Derick Cluley, FICO's country manager for South Africa. "The healthcare payment process is complex, dynamic and involves many parties. FICO's payment integrity solution accounts for this and offers opportunities for dramatic reduction in fraud, waste and abuse losses, improved governance, regulatory compliance and transparency, and improved productivity."

"Schemes will be able to avoid losses upfront through catching aberrant claims prior to payment, and they can focus investigative resources where they produce the greatest financial impact," Midlane said. "This will undoubtedly be welcome news for the industry."

About AfroCentric Health Group:
AfroCentric Health Limited, formerly known as Lethimvula Investments Limited, is the healthcare arm of AfroCentric Investment Corporation Limited and houses AfroCentric's healthcare companies which focus on: Health administration, Health risk management, HIV/Aids disease management as well as Health-centric information and communications technology-based solutions. Entities under AfroCentric Health include: Helios IT Solutions, Allegra, DBC South Africa, Aid for Aids and its largest entity Medscheme Holdings.

Medscheme is the largest health risk management services provider and is among the leading medical scheme administrators in South Africa with over 3 million lives under management. Its clients include two of the country's largest open medical schemes, Bonitas and Fedhealth, as well as several closed schemes. Medscheme has over four decades of experience in the healthcare industry and currently employs 3200 employees.

About Helios ITS
Helios IT Solutions (Pty) Limited is an innovative ICT services provider that specializes in the healthcare industry. We view technology as a strategic enabler that allows us to deliver service excellence in an affordable and sustainable way. Our primary focus is on offering technology-based solutions to the healthcare industry in South Africa. However, we have also extended our reach to the rest of Africa (with a specific focus on Zimbabwe and Swaziland) and internationally. We offer comprehensive IT services that encompass the use of a range of networking, development and IT administrative tools.

About FICO
FICO (NYSE: FICO), formerly known as Fair Isaac, is a leading analytics software company, helping businesses in 90+ countries make better decisions that drive higher levels of growth, profitability and customer satisfaction. The company's groundbreaking use of Big Data and mathematical algorithms to predict consumer behavior has transformed entire industries. FICO provides analytics software and tools used across multiple industries to manage risk, fight fraud, build more profitable customer relationships, optimize operations and meet strict government regulations. Many of our products reach industry-wide adoption. These include the FICO^® Score, the standard measure of consumer credit risk in the United States. FICO solutions leverage open-source standards and cloud computing to maximize flexibility, speed deployment and reduce costs. The company also helps millions of people manage their personal credit health. Learn more at www.fico.com.

For FICO news and media resources, visit www.fico.com/news.

FICO is a trademark or registered trademark of Fair Isaac Corporation in the US and other countries.

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SOURCE FICO

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