Impact of Waste and Overuse on Healthcare Industry Sustainability
Explore the challenges and governance strategies in combating waste and overuse in the healthcare industry, with a focus on audit statistics and the use of big data analytics for detection. Discover how Daman Health is leading efforts to protect healthcare funds and quality through specialized teams and control measures.
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Presentation Transcript
Waste and Overuse Impact on Healthcare Industry Sustainability Dr. Ali Anees damanhealth.ae damanhealth.ae
Waste and Overuse | Overview A global challenge to the healthcare industry Healthcare industry growth in UAE is a successful journey Collaboration between the providers and payers is highly supported by regulators Structured and standardized billing schemas, that are highly codified 3-10% US estimated waste and overuse of the healthcare spending according to the 2011 FBI Journal Waste and Overuse is an anomaly of the healthcare industry damanhealth.ae 4/4/2025 2 damanhealth.ae
Waste and Overuse | Framework and Governance Daman heavily invested into resources and systems to detect fraud waste and abuse to protect the funds of its members Availability of whistleblowing platforms internally and externally Specialized team with medical, coding, analytical, and audit expertise Control measure to reduce unnecessary healthcare expenditure Obligation to protect members fund and healthcare quality Helpline to anonymously report any suspicions of waste and overuse National media campaign to raise awareness Referral to the appropriate regulatory authority and delisting from network Criminal prosecution and civil recovery damanhealth.ae 4/4/2025 3 damanhealth.ae
Waste and Overuse | Audit Statistics Focused and stratified sample of paid claims Health insurance misuse and abuse is inherit in every health insurance system. Vulnerabilities or major audit findings are tracked for purposes of developing and monitoring corrective measures. Billing of non- covered services 2% Inconsistency with medical records 4% >3,000 providers Lack of Miscoding 5% Documentation 26% Unbundled Services 7% >6,000 audit visits >2 million claims/medical record Duplicate claims 8% >100 suspected fraud cases reported to Billing of services not rendered 21% the regulator Unjustified services 13% Upcoding 14% damanhealth.ae 4/4/2025 4 damanhealth.ae
Waste and Overuse | Big Data Analytics Patterns & behaviors The use of data mining tools and predictive analytic technology is becoming more and more essential to identify suspicious billing patterns. Variety of methods are used to detect misuse and abuse schemes Data mining tools Social network analysis Predictive modeling damanhealth.ae 4/4/2025 5 damanhealth.ae
Waste and Overuse | Focused Behavioral Interventions Daman s know-how in tackling outliers Trend Analysis and Focused Behavioural Interventions Fair local benchmarking and peer reviews Standardized and codified claims data support big data analytics Excessive behaviour lies above a set percentile threshold of the local market Positive shift towards improvement in the utilisation behaviour damanhealth.ae 4/4/2025 6 damanhealth.ae
Waste and Overuse | Intervention Outcomes Laboratory Spending 2015 - 2017 AED Intervention #1 Intervention #4 Intervention #3 Intervention #2 Jul Jul Feb Feb Aug Nov Aug Nov Mar Mar Mar Jan Apr Jan Apr Jan Apr Sep Sep Jun Jun May Oct May Oct May Dec Dec Feb 2015 2016 2017 damanhealth.ae 4/4/2025 7 damanhealth.ae
Waste and Overuse | Our Responsibility All stakeholders across the healthcare industry have a responsibility to ensure sustainability of the industry and need to work collaboratively to fight and prevent waste, fraud, and abuse Focused Behavioural Interventions based on clinicians and members behaviour is more effective and efficient in comparison to a claim to claim review which has proven to be less effective Artificial Intelligence Predictive Modeling Trend Analysis Big Data damanhealth.ae 4/4/2025 8 damanhealth.ae
Thank you damanhealth.ae 4/4/2025 Document type 9 damanhealth.ae
