Top HC IT Product Dev Plan v0.1

# 1.
FRAUD MANAGEMENT SYSTEM
Smart Product Innovation

Intellectual Detection
A Fraud Management System in the healthcare domain is crucial to safeguard against financial losses and ensure the
integrity of medical transactions.
It employs advanced algorithms to detect anomalies, potentially fraudulent activities, and irregular patterns within
healthcare billing and claims data.
Real-time monitoring is a key feature, allowing immediate identification of suspicious activities, reducing the risk of
fraudulent claims slipping through undetected.
The system integrates with electronic health records, insurance databases, and billing systems to analyse data
comprehensively.
Machine learning models play a vital role, continuously evolving to adapt to new fraud patterns and techniques,
enhancing the system's effectiveness over time.
Automated alerts and notifications enable quick response to potential fraud, facilitating timely investigation and
mitigation.
Collaboration with law enforcement and regulatory bodies is often built into the system, aiding in the swift resolution
of detected fraudulent activities.
Continuous auditing and regular updates ensure that the Fraud Management System remains robust and aligned with
evolving healthcare regulations.
Education and training modules for healthcare professionals and staff help create awareness and prevent inadvertent
involvement in fraudulent practices.
Ultimately, a well-implemented Fraud Management System in healthcare contributes to maintaining the financial
health of healthcare institutions and preserving the trust of patients and insurers.
Health Insurance Sector Pain Areas
Challenges to find Sources of Fraud areas.

Mismanagement of Claim Processing
High dependency on Third-party sources / investing on manpower for physical inspection.
Huge Investments on Investigations
Inaccurate Fraud Detection
BENEFITS WE ARE FOCUSING
CONTROL OVER THE INSURANCE NETWORK

Rely on Technology
ENTERPRISE DATA INTEGRATION

Ensure all Insurance Entities are connected.
SAVE MONEY
Reduce the Operational Cost
FOCUS ON BUSINESS DEVELOPMENT

Spread your Business.
ARTIFICIAL INTELLIGENCE
Reduces Manpower / Avoid Mishandling
TARGET CUSTOMERS
Product helps Insurers / TPA’s / Brokers to control the Health Insurance Sector Frauds
Insurers: Recommend the Product to plug in Hospitals

TPAs: Being common Interface across all entities, Product need to be implemented for qualitative fraud management.
Brokers: Major analytics can be implemented, who has control over Insurer network
TECHNOLOGIES
Web Application Development using .NET Framework

Master Administration
Transactions
MIS Reports
Web Service Development / Implementation

Web API
Web Services
SOAP/Restful
Mobile / Tab Based App Development

Android Development
iOS Development
Responsive Web Development
Cloud Solution
Cloud Storage / Cloud Computing
High Security & Data Privacy
PRODUCT BENEFITS
REAL-TIME DATA EXCHANGE

Integrated fraud management provides real-time fraud Data exchange across the authentic business entities.
REAL-TIME FRAUD ALERTS

During claim processing, system alerts fraud alerts based on intelligence built:
1. Suspicious
2. Fraud with <<Entity>> <<Scaling>>
REAL-TIME FRAUD SURVEY

Based on the claim data build, system applies extensive business logics/rules/artificial intelligence and provide the
survey on the frauds
ANTI-FRAUD COMMAND CENTER

Real time governance of fraud networks/fraud sources/fraud entities & commonalities – Dashboard provides the hints
for Prevention / Quick decision making in the healthcare sectors.
# 2. TRIPARTITE SYNCLAIM
Payer Integration Service
PURPOSE
• It provides an auto-synchronization of cashless claims between the Hospitals, respective TPAs and Insurance
Company.
• All cashless claims requested by the Hospitals are automatically submitted to the TPAs/Insurance company.
• Claims Meta Data is managed at Insurance company level.
Pain areas of Current System
• Claim Submission is currently a manual process and tedious job.

• Claim Settlement status and data is also a manual job to map it within internal hospital level.
• Manual errors are leading to many iterations/queries pending for claim settlement.
• Too many resources utilization
• Turn Around Time of Claim Submission to Settlement is too high.
• No Big picture across the business
Features
• Seamless integration of Claims data among Hospital, TPA and Insurance Company
• Minimal Manual errors with minimal staff
• Quick Claim Submission
• Easy of Claim Settlement Status Update to Hospitals
• Easy to track the claim at Hospital / Insurer level (for Quick Future Reference)
• Secured and Centrally managed Claims data across Hospitals on Cloud Storage
Benefits to Insurance Company
• Cashless Claims Transparency

• Online dashboard about TPA Settled Cases, Hospital Cashless Claims
• Monitoring and Tracking of Retail Claims
• Insurance company intervene with TPA during Claim Process through system.
• Faster Claim Settlements leads Business Development / Growth in the market
# 3. Green Health Card
Green Cross (+) Health Cards are verified versions of your clinical information, such as vaccination history or test results.
They allow you to keep a copy of your important health records on hand and easily share this information with others if
you choose. SMART Health Cards contain a secure QR code and may be saved digitally or printed on paper.
Health Card allows the patients to carry their own card handy
and scan the QR Code to check family health profile with
security and share it to healthcare workers.

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# 1.

FRAUD MANAGEMENT SYSTEM

Smart Product Innovation

Health Insurance Sector Pain Areas

Challenges to find Sources of Fraud areas.

BENEFITS WE ARE FOCUSING

CONTROL OVER THE INSURANCE NETWORK

ENTERPRISE DATA INTEGRATION

FOCUS ON BUSINESS DEVELOPMENT

Insurers: Recommend the Product to plug in Hospitals

Web Application Development using .NET Framework

Web Service Development / Implementation

Mobile / Tab Based App Development

REAL-TIME DATA EXCHANGE

REAL-TIME FRAUD ALERTS

REAL-TIME FRAUD SURVEY

ANTI-FRAUD COMMAND CENTER

Pain areas of Current System

• Claim Submission is currently a manual process and tedious job.

• Cashless Claims Transparency

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