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Solving Challenges for Healthcare with Data and Analytics
29 July, 2016
Civica Company Overview - Group Performance
Civica Company Overview
Civica Company Overview - Healthcare Northern Hemisphere
200
200 NHS Trusts using
Civica Systems
£40billion
£40 billion of NHS Funds
processed annually
Cloud Delivery to more
than 20,000 Clinicians
Annual Care Billing of
over £3 billion
200 million documents &
images scanned annually
ColdharbourPart of the Civica Group
Civica Health Solutions
CivicaHealth Solutions - Australia
33%PHI Policies
25%ECLIPSE Online Eligibility Checks (OEC)
42%OSHC Policies
Focus on:• PHI Solutions• OSHC Solutions• OVHC Solutions• Automation• Industry Solutions
$5.9 BillionBenefits Paid
5 MillionActive Customers
$6.2 BillionReceipts
2.5 MillionActive Policies
‹#›
Revenue: US$4.8 bn
EBIT: US$1.2 bn
Market Cap: c.£14.3 bn
In top 50 of FTSE-100
Employees: c.17,000
Offices in 39 countries
Largest markets: US, Brazil, UK
For the year ending 31 March 2014
…helping organisations and consumers derive insights and make informed decisions
Experian Company Overview
‹#›
Global Network
Expertise
Platforms
Analytics
Data
Management
Data
Throughout the world, we help organisations and consumers
derive insights and make informed decisions
ExperianGlobal information services leader
‹#›
Data
Analytics and Workflow
Consumermarketing
c. 270mhouseholds
globally
US Healthcaredatabase
c. 1.2b annual health visits in US
Businesscredit
c. 99m businesses
globally
Consumercredit
800m+consumers
globally
Consumer segmentation
2.3b consumers
Vehicledata
c. 700mvehicles in
U.S. and UK
Consumer purchasing behaviour
c. 100mU.S. households
Depth and Breadth of our Data Assets
Australian healthcaredatabase
Visibility to
significant
portion of US
healthcare
activity
Possible callout of AUS
or Civica data assets
‹#›
Experian HealthTrusted by payers and providers to solve complex challenges
Facilitate system
wide movement of
money and data
Pool benefits data on
130m patients for
efficient management
Qualify patients for
charity care or financing
Segment patients for
marketing, communication,
and risk stratification
Link data from across
healthcare to single
individual
Detect and prevent
wide range of fraud
activity
‹#›
US Healthcare MarketSize and complexity represent opportunity for data and analytics
Experian Health solutions use connectivity, data, and analytics to
optimise flow of payments between patients, providers, and payers
~$1.6 trillion in hospital and physician services
US Healthcare payment flows:
Patients
Point of service
Remaining balance
6.5%
5.5%
37%
51%
Premiums
Claims
Commercial
Payers
(Private
funds)
PremiumsEmployers
Patients
GovernmentPayers
Providers
Premiums
Claims
‹#›
Magnitude of US Healthcare FraudMassive and growing problem, with medical data now targeted by hackers
$300 billion estimated losses due to some form of fraud in US healthcare
112 million health records stolen in 2015, often
precursor to insurance fraud
20xvalue of stolen health record,
versus credit card account
Reasons healthcare is targeted
$571 million Federal budget allocated exclusively
to investigating healthcare fraud
‹#›
Healthcare Fraud, Waste, and AbuseBlurred lines make detection and measurement difficult
Waste Abuse FraudLow High
Intent to Deceive
WasteDirect or indirect negligent
or wasteful acts that result
in unnecessary costs.
AbuseDirect or indirect act that
results in unnecessary costs
without intent to receive
an improper payment
FraudIntentional act or
misrepresentation to receive
improper payment or
benefit.
Separated by intent, but can be addressed by the same solutions
~$30 billion~$270 billion
‹#›
Multi-Layer Approach to Reducing LossesKey is pooling and linking of data assets
Big data
analytics
fueled by
identity and
data
foundation
Universal Identity Management
Essential foundation to analysis
Fraud: identity theft; outright intent to deceive
Prevent through industry-wide data sharing
Abuse: such as excessive prescription use or intentional
duplicate testing
Waste: poor coordination; avoidable errors
‹#›
Healthcare Fraud
Bureau
Universal Identity ManagementIdentifier that persists across providers and funds is key to fighting fraud
Private Fund
Civica and other 3rd Party Data
Experian data
Universal Identity Management
Pooling and linking disparate data assets creates powerful fraud fighting tool
► Cross-industry analysis
► Enrich with 3rd-party data
► Analyze trends and velocity
‹#›
RecoveryDetection
Screening for Fraud/Waste/AbuseMedDetective – Investigate claims before payment
Prevention
Low returns from “pay and
chase model”
In 2013, US recovered <1%
Experian MedDetective
MedDetective scores provider fraud risk at
enrollment and monitors continuously,
leveraging broad Experian data assets: Commercial credit and firmagraphics
Small business owner links and consumer credit
Medical license data
Fraud database
Device intelligence and geo-location
‹#›
Fraud PreventionMedDetective solution dashboard
‹#›
Emerging Trends in US Payer MarketOther uses of Experian data to solve emerging healthcare needs
Financing large obligations
Credit underwriting to make
payment more convenient
Marketing segmentation to
enhance communication
Payers moving into patient payment
stream to earn additional revenue
and deepen relationship
TREND
OPPORTUNITYBetter serve most
valuable plan members:
Online portals allowing access to
patient records being targeted by
hackers for use in fraud schemes
Providers and payers are
implementing bank-level identity
verification to secure access
points, such as: Benefits enrollment
Patient portals and records
ePrescribing
Telehealth services
‹#›