health-insurance

Health Insurance Industry

Our assessors are adept at assessing all manner of health insurance claims to ensure that all payable claims are valid. Take a look at our areas of service…

Health Claims

When health claims are in question, EOH offers the following services:

  1. Data integration or capturing of all claims information utilising call centre processes and infrastructure.
  2. Application of predictive analytics to segment high risk claims for further investigation – i.e. relationship mapping and checking against fraud database.
  3. Use of layer voice analysis to confirm fraud / corruption hypothesis for proper planning and action by assessors.
  4. Enabling underwriters to finalise valid claims within required time frames – dependant on provider specific requirements.
  5. Desktop and on-the-road assessment, examination and verification processes to ensure proper action is taken against unscrupulous fraudsters.
  6. Objective medical opinions by expert medical practitioners.

The above processes include the application and policy assessment and verification, interviews with all direct / indirect parties involved, ombud / regulator enquiries management as well as record keeping of all involved in the criminal schemes.

 

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