BRMS-based System To Reduce Claim Fraud and Costs by 30 Percent
SUNNYVALE, Calif., Oct. 1 /PRNewswire-FirstCall/ -- ILOG(R) (Nasdaq: ILOG, Euronext: ILO, ISIN: FR0004042364) today announced that Swiss Medical Group, a leading medical services provider in Argentina, is using ILOG JRules(R) to automate its medical claims processing. With the new Claims Excellence Application(R), Swiss Medical has been able to reduce unnecessary medical treatments, provide faster payments to practitioners, and lower incidents of fraud and abuse. With ILOG JRules as a key part of its new, more efficient system, Swiss Medical is able to automate rules across multiple clinics while reducing costs.
Swiss Medical has grown to over 60,000 practitioners and 730,000 patients in the past 18 years by providing extra services using a personalized plan. With over 2 million claims per month, a laborious and vulnerable paper-based system for claims processing became inefficient. ILOG JRules was incorporated into Swiss Medical's automated system to unify business rules throughout Swiss Medical's entities and to streamline its claims processing. With ILOG JRules, Swiss Medical is automating such functions as fraud detection, claim assignment and adjudication, and payment and settlement.
"ILOG has been instrumental in helping us implement our Claims Excellence Management project," said Luciano Graffi, database administrator, application architecture and operations management, Swiss Medical Group. "This project focused on achieving short- and medium-term monetary gains by incorporating a wide set of rules that span across the claims process. Using ILOG JRules to standardize our claims process, we have reached our goals of becoming paperless, eliminating process silos, and reducing fraud and abuse. In addition, the new system has enabled us to reduce claim costs and fraud by an estimated 30 percent, resulting in significant savings."
Automating the claims process and centrally maintaining and managing the business rules with the utmost of transparency have made a significant impact on improving efficiency. With the previous system, conspiracy to defraud between medical students, practitioners, patients and internal personnel was problematic and difficult to control. Today, deception is avoided by electronically processing claims using ILOG JRules and avoiding long-standing contracts between the claims processor and the practitioner.
Prior to automating the system, fraudulent claims were not easily identified; this resulted in payment for procedures not covered under the government's healthcare plan. Today, false claims are detected with ILOG JRules and are efficiently processed by determining what percentage of each procedure is covered by the government and which portion can be paid for by the Swiss Medical Group plan.
ILOG has consistently built on its history of product innovation to make it one of the industry's leading providers of business rule management systems (BRMS). Forrester Research has recognized ILOG as a resounding leader in Business rules platforms, including the sole leader in rules platforms for .NET, a leader in business rule platforms for Java, for business analysts and for overall feature sets. Customers of ILOG's award-winning BRMS products include eBay, Equifax, Grupo Santander, Travelocity, Visa and many other leading Global 2000 companies and governments worldwide. ILOG's BRMS product line includes ILOG JRules(R), ILOG Rules for .NET(R) and ILOG Rules for Cobol(R) To learn more about ILOG's BRMS products, please visit http://www.ilog.com/products/businessrules.
ILOG delivers software and services that empower customers to make better decisions faster and manage change and complexity. Over 3,000 corporations and more than 465 leading software vendors rely on ILOG's market-leading business rule management system (BRMS), supply chain planning and scheduling applications, as well as its optimization and visualization software components, to achieve dramatic returns on investment, create market-defining products and services, and sharpen their competitive edge. ILOG was founded in 1987 and employs more than 850 people worldwide. For more information, please visit http://www.ilog.com.
ILOG, ILOG JRules and ILOG Rules for .NET are registered trademarks of ILOG S.A. and ILOG, Inc. All other company and product names are trademarks of their respective owners.
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