A Government program in Puerto Rico was originally designed to provide health benefits to indigent workers.
The insurance cards were issued by four private companies and were later reimbursed by the Government to administer the benefits.
The program became plagued with significant fraud concerns as qualified participants were known to loan or rent their insurance cards to others, thereby providing non-qualified people access to the government healthcare benefits.
Working with the Government of Puerto Rico, Enterprise Iron’s Integrated Project Team developed a solution deploying two (2) basic Anti-Fraud mechanisms:Identity Verification Verifying the identity of a person received significant attention across government elections as well as Healthcare and Financial Services industries. The simplest form of Identity Verification is with photo ID, but in this case, a photo could not be included on the insurance card for social and political reasons. Data Mining The other primary method used to address fraud is data mining. Any system with large groups of people produces data that can allow administrators to develop profiles of normal behavior and then analyze the data for behavior that falls outside of established norms.
Our approach to mitigating fraud involved three (3) strategic phases and six (6) stages:
RESULTS & CLIENT BENEFITS
With this revamped process, the Government of Puerto Rico significantly reduced the recurring fraud instances and deterred further abuse of the system by new participant enrollees.
While political decisions prevented the prosecution of fraudsters, the overall costs of the program were reduced on a per participant basis.
This cost reduction also allowed for greater enrollment coverage for indigent workers.