IBM and PRO BTP Use Analytics to Fight Healthcare Insurance Fraud and Abuse

- Deployed in the cloud, the platform enables the fight against fraud and abuse in optical and dental care
- The solution will be deployed in other medical specialties and life and protection insurance

ARMONK, N.Y. - 16 Oct 2014: IBM (NYSE: IBM) today announced that it signed a seven-year agreement with PRO BTP, one of the primary welfare institutions in France, to fight healthcare insurance fraud. Built with IBM’s Smarter counter fraud Software and Services, the new SOLON cloud business solution uses advanced analytics to detect fraud patterns and suspicious activity, qualify them in real time, and decide how they should be treated.

The growth of electronic transactions has given rise to new opportunities for fraud and abuse. For example, improper payments today represent between 5 and 7 percent of all reimbursements made today by PRO BTP. The new SOLON platform allows the insurance provider to identify issues at the moment of payment for optical and dental reimbursements. As a result, PRO BTP will be able to reduce the volume of fraudulent transactions, reduce costs and improve service.

“It is very important for PRO BTP to ensure that membership fees are actually used to cover the needs of members and to decrease the cost of insurance,” said PRO BTP CEO Paul Grasset. “This is the goal of the platform developed with our partner IBM which has proven expertise in fighting fraud.”

Delivered in the cloud, the SOLON platform uses IBM’s advanced analytics solutions and services to analyze millions of data points held by PRO BTP and identify and predict suspicious claims and activity in real-time across both optical and dental domains. During a recent pilot using 21 months of PRO BTP data, the platform was able to identify suspicious activity in 9 percent of optical and 14 percent of dental insurance claims, amounting to €14 million in potential losses. This detection was achieved through the use of IBM’s predictive analytics solutions and the integration of numerous sources of data.

Silvano Sansoni, Vice President, Industries and Business Development, IBM France added: “We are delighted to bring our deep knowledge of data management and our expertise in counter-fraud and abuse solutions and services to PRO BTP. This is a joint development partnership and the outcome of huge IBM investments. It supports this new idea that fraud cannot and must not be considered as a cost of doing business.”

The two companies plan to extend the SOLON platform to other medical specialties such as hospitalization, pharmacy, audiology and prosthesis benefits as well as life insurance.

About PRO BTP

A social protection group for the Constuction and Public Sectors, PRO BTP serves 3.5 million members and 208,000 businesses. With A non-profit and joint management principles, PRO BTP offers benefits and services to employees, retirees, craftsmen and construction companies in the area of pensions, health care, savings, insurance, social action and holidays.
The Group has a network of 114 local advice agencies located throughout France to welcome, inform and advise its members.
In 2013, PRO BTP was the country's leading professional social protection group, with activities amounting to 6.5 billion euros of which 3.7 billion resulted from pension contributions and 2.7 billion in contributions relating to personal insurance (life and individual protection insurance, supplemental health insurance and personal savings).

About IBM

For more information about IBM’s Smarter counter fraud initiative, visitwww.ibm.com/smartercounterfraud.

Follow the conversation on Twitter at #counterfraud

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