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CONFIDENTIAL
GenKey ClaimSync
Better Healthcare through Technology
29th of June, 2015
2nd Annual Southeast Asia Healthcare Summit
Arnd Langguth, Director Sales & Business Development
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CONFIDENTIAL 2
About Genkey
Solutions to prevent Identity Fraud with a focus on Emerging Economies
• National Election solutions (e.g. Ghana, Cameroon, Mozambique)
• Large-scale Health applications (e.g. NHIA Ghana)
• The core of Genkey is spin-off out of Philips®
• Solutions based on own technology and R&D
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Fraud in public+private Healthcare
• Patient induced - Impersonation, “sharing” an insurance - Selling prescribed medication
• Provider induced - Claiming w/o having seen the patient - Overbilling
• Fraud induced within the payer system
- Ghost patients
- Sale of medication (esp. from donor’s programs)
3
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First Visit Insur No Sex Age G-DRG ICD 10 Diagnosis
2-Apr-13 71923004 F 29 OPDC06A A09 OTHER GASTROENTERITIS AND COLITIS
2-Apr-13 71923004 F 29 ZOOM02A T63.0 ANIMAL BITES >12YRS
4-Apr-13 71923004 F 29 OPDC06A D50. IRON DEFICIENCY ANAEMIA
4-Apr-13 71923004 F 29 OPDC06A K27 PEPTIC ULCER
5-Apr-13 71923004 F 29 OPDC02A ---- ANC
5-Apr-13 71923004 F 29 OPDC06A L23.9 OTHER ALLERGIC SKIN DISEASES
5-Apr-13 71923004 F 29 OPDC06A D50. IRON DEFICIENCY ANAEMIA
6-Apr-13 71923004 F 29 OPDC06A K27 PEPTIC ULCER
10-Apr-13 71923004 F 29 OPDC06A B54 MALARIA
14-Apr-13 15-Apr-13 71923004 F 29 OBGY33A - SPONTANEOUS VAGINAL DELIVERY
15-Apr-13 19-Apr-13 71923004 F 29 OBGY32A O62.9 DYSFUNCTIONAL LABOUR
15-Apr-13 71923004 F 29 OPDC06A .. ALLERGIC CONJUCTIVITIS
15-Apr-13 71923004 F 29 OPDC06A T14.3. STRAINS OF MUSCLE, LIGAMENTS AND TENDONS
15-Apr-13 71923004 F 29 OPDC06A A09 OTHER GASTROENTERITIS AND COLITIS
15-Apr-13 71923004 F 29 OPDC06A - MALARIA IN PREGNANCY
16-Apr-13 71923004 F 29 ZOOM02A I67.9 CEREBROVASCULAR ACCIDENT (CVA)
18-Apr-13 71923004 F 29 OPDC06A A09 OTHER GASTROENTERITIS AND COLITIS
18-Apr-13 71923004 F 29 OPDC06A L01 IMPETIGO
22-Apr-13 71923004 F 29 OPDC06A H26.9 ALL TYPES OF CATARACT
25-Apr-13 27-Apr-13 71923004 F 29 MEDI23A A09 OTHER GASTROENTERITIS AND COLITIS
25-Apr-13 71923004 F 29 OPDC06A D50. IRON DEFICIENCY ANAEMIA
25-Apr-13 71923004 F 29 OPDC06A B54 MALARIA
26-Apr-13 71923004 F 29 OPDC06A J99. R.T.I
Example of fraud within NHIS Claims on behalf of 1 subscriber 24 visits
Source: National Health Insurance Authority Ghana
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ClaimSync Embedding Identity in the Healthcare cycle
Verification
Registration and Card issuance
Health insurance
Member Health provider
Claim Processing
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Member Registration Office
Claim Processing Center
System Overview
Healthcare Provider
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Member Registration Office
• Create a duplicate-free member database
• Issue a member card Member Registration takes place at a registration center: • Collect biographic data • Collect biometric data • Send biometric data to Central Data
Center for de-duplication • Store member data in central
database • Issue biometric member card
Reg
istr
atio
n O
ffic
e
Cen
tral Data C
enter
De-duplication
Cen
tral D
atabase
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Healthcare Provider
• The patient has to proof his identity with a fingerprint
• A Claim Verification Code (CVC) is generated after a correct member verification
• It ensures that the member was present at the time the CVC was generated (proof-of-presence)
• CVC generation is an off-line process
• The CVC must be noted on the invoice
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Healthcare Provider CVC Generation
Claim Verification
Code
• The CVC is a 10-digit number that is added to a claim • ClaimSync has been designed to be easily integrated in existing healthcare systems
and supports both paper-based and digital claims
HP ID Date Member ID CVC Other data
Biometric Info BioHASH®
HP ID Claim Date
Context Info
Member number
Biographic Info
Proof of Presence: CVC can only be generated if card-holder is present
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Claim Processing Center
• Claim Vetting /Tracking/Auditing takes place at a Claim Processing Center
• The CVC added to the claim allows a simple check-of-authenticity
Biometrically-certified claim
(CVC)
Standard Claim Vetting/
Tracking/Auditing
Claim Payment
Authenticity check using CVC
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GenKey Reference
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National Health Insurance Scheme (Ghana)
25 Million citizens
NHIS established in 2003 to “secure provision of basic healthcare services to persons resident in the country”
In Partnership with
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NHIS – Ghanaian National Health Insurance Scheme
• Fund: exceeding USD 300 Mio per year
• Fund created by 2.5% of VAT on goods and services
• Already 4 Mio+ citizens registered with biometrics
Solution provided:
• Registration at 280 NHIA service points:
• Biographical + Biometrical information
• Direct delivery of a membership cards
• Solution for 3000 Healthcare service providers:
• Biometric verification of patient
• Creation of the “Biometric Claim Check Code”
• Central solution for de-duplication
• Solution for automatically verifying authenticity of claim
Reference: Ghana NHIS
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Source: 2011 NHIS annual report
1 USD = 2 GHS
Cla
ims
pay
me
nt
tre
nd
(G
HS
Mill
ion
s)
Year
Claims payment trend increased to USD 275 Million in 2011
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$7.4 million Amount charged through fraudulent claims
by providers and recouped by Ghana’s
NHIS in the last two years
Source: Joint Learning Network.
Huge Savings
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Embedding Identity – further examples
• Medication: Extending the “proof of presence” down to the pharmacy as a “proof of receipt” - Linking medication to an identity makes fraud very difficult
• Government / International donors Creating a database of entitled individual for donated medication, enabling a full audit trail on the medication received
• Healthcare passports in International Aid projects Clear proof of identity to avoid the high costs of re-examinations
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Embedding Identity in the Healthcare cycle
• Ensures correct member identity using cost-efficient member cards
• Results in improved quality of service to members
• Enables tamper-resistant claim generation/verification using unique biometric proof-of-presence
• Supports both electronic and paper based systems
• Leverages on existing process flow
• Easy integration into existing systems of member registration and claim handling
• Supports efficient and transparent claim handling process
• Suitable for Government and private sector
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Embedding Identity in the Healthcare cycle
• Patient induced - Impersonation, “sharing” an insurance - Selling prescribed medication
• Provider induced - Claiming w/o having seen the patient - Overbilling (*)
• Fraud induced within the payer system
- Ghost patients
- Sale of medication (esp. from donor’s programs)
19
(*) We can help with that as well – ask the speaker
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CONFIDENTIAL
GenKey High Tech Campus 69 5656 AG Eindhoven the Netherlands www.genkey.com
Thank you very much for your time!