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Detection of Potentially Incorrect Reporting of Medical Care by Medical Facilities – PANDA Solution

Medical care reported by medical facilities goes through a verification system during the processing of information. This verification is usually based on application of a set of pre-defined rules. The PANDA system adds new procedures to these standardised verification processes created with the help of advanced analytical methods (data mining), which can more accurately uncover incorrectly reported medical care and reduce potential loss.

Key benefits of the PANDA solution

  • The basic output is a list of medical facilities categorised according to their “hypothetical loss” in CZK for a certain time period (normally one calendar year), which for a health insurer represents potentially incorrect reporting of medical care.
  • Based on the provided list of medical facilities reporting the highest hypothetical loss, it is possible to perform verification inquiries in the particular medical facility or conduct physical verification.
  • The system works on the basis of statistical profiling using advanced analytical methods. This can potentially uncover non-standard medical care reporting, not based on predefined rules, but based on dynamic comparison with a typical medical facility in the particular group.

Our competitive advantage

  • The PANDA system can be used either via periodic service or deployment directly at the customer’s end, including integration with the health insurer’s base and reporting systems.
  • PANDA is modular. In the basic version, 8 analytical models are deployed, each of which is parameterised for the particular customer’s situation. Partial detection models are aggregated into a summary description.
  • KOMIX is continuously developing the PANDA system, including the addition of further modules and processing information about medical facilities from online sources.