Digital Innovation to Prevent Insurance Fraud

Bali, October 11th 2017

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Big Data AnalyticsHealth Risk ManagementFraud Management

DigitalDocument

Digital Payment +500 Merchant Network

Hospital Information SystemHealth, Travel & PersonalAssistance

Mobile Health App

Healthcare EquipmentsOn-site MCU

On-site Clinic

+4,2Members

Million +92Insurance, Corporations, SOE’s

Clients

ISO 9001:2008Quality Management

ISO 27001:2013Information Security Management System

PatentedSystem EDC

+3.600National Health careProvider Network

+40.000International Health careProvider Network on 273 countries

AdMedika at Glance1

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Go beyond TPA by becoming Total Health Solution provider through digital innovations to lead Indonesian digital healthcare integrated solution and platform

• From 2002 – 2009 prior to joining Telkom Group, AdMedika solely focus on its core business, providing Health ClaimManagement services for private sector insurance with group insurance coverage.

• From 2010 - 2014, AdMedika mark the starts of its journey of transformation by changing the corporate logo in 2013and started to expand its business by providing health claim management (private insurance, SOE, and self insured),HiSys, and i-Assist

• AdMedika has transformed into a Total Health Solution providers by acquiring Telkomedika in 2016 to expandhealthcare services solution. Admedika also provides digital solutions such as mobile applications, big data, anddigital claim management.

2002 – 2009 2010 – 2014 2015 – 2017

Third Party Administrator (TPA) Modern TPA Total Health Solution

Insurance Companies(group coverage)

Healthcare Providers

SOE’s & Self Insured

PharmacyInsurance Companies(individual coverage)

General Public (B2C)

AdMedika at Glance1

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Insurance Industry | Fraud Challenges

data protection

and privacy

Emerged digitization and the increase

of data in recent years mean that insurers

have an even greater responsibility to

keep customer data secure and

confidential

Access to

External Data

External data improves thehealth of insurance portfoliosby seeking the right balance in

risk coverage.

Opportunity for improvement in

how we record information and

changing manner in registration

system

Information that is shared at this moment

mostly comprises claim history and fraud

cases. Insurers do so to improve onfraud and risk detection

Successfully detectingorganized fraud also differs per

culture and often is a sensitive

occasion. However, the more

effort a fraudster needs to put in

to commit fraud, the less

attractive fraud becomes.

Fraud Solution can go hand in hand

as most solutions are easy to

integrate in any core systemand should complement eachother.

Source: FRISS, 2017

Internal Data

Quality

Cooperation with

other insurersModern Fraudster

Modus OperandiNot a Priority for IT

In order to fight fraud effectively, it is

critical to establish fraudawareness throughout theentire organization

Commitment from

the Organization

possible fraud cases is most efficient

if all related information is availablein one system. Unfortunately, a

great number of insurance

companies still rely on manualprocesses

Outdated Internal

Fraud Systems

2

Develop rules & regulation that emphasize on ICT.

Fighting fraud is an ongoing process of adaptation and optimization

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3 AdMedika | Positioning

Fraud Management

Membership

Financial

Facility

• Benefit• Coverage

• Claim Duplication• Excessive Use• Up-coding & unbundling• Exclusion• Length of Stay• Fictitious Claim

• Over Cost

Semi-Automatic

Fraud DetectionRemark warning alert

Periodically ReportVia FTP

Concurrent

Retrospective

Inpatient data

Outpatient data capture

Claim Transaction data

Length of Stay

Cost

Utilization

Procedure/Flow

Cost

Frequency

Length of Stay

Cost

Frequency

Health

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4 AdMedika | Fraud Solution

People

20 doctors422 nurse563 Midwife

24/7 Monitoring

Dedicated Unit Process

Member Checking

Single ID

Real time

TechnologyAdCPS

Finger print for eligibility

Verification process

Claim processing system

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NFC

Printer

LCD Touch

Fingerprint Scanner

IC Card Reader

Camera

Battery

Swipe Card

KTP Electronic ReaderPopulation (Dukcapil) Data Verification & Validation

Mobile Point of Sales (MPOS)Magnetic Card, Smart Card, Contactless Card, QR Code, Biometric and Print

Fraud Solution | Finger Print for Eligibility4

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Fraud Solution | One-Time Password4

SMS CENTER

AdMedika Claim Processing System

Swipe

OTP

Not Eligible

Eligible

Report

GrantOTP

(1)

(2)

(2a)

(3)

(4a)

(5)

(4b)

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Fraud Solution | Member Checking4

Existing New

AdMedika Member Integration

A B C D E A B C D E

A B C D E A B C D E

Insurance Insurance

MemberMember

• Membership• Claim• Alert System

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5 AdMedika | Conclusion

AdMedika will focus in digital

innovation for prevent fraud through

automatic engine alert

• Member Checking & Single ID

Regulation to improve on fraud &

risk detection

• Member enrollment standardization

• Preventive & Curative Standard

procedure for fraud

Struggletoday

strengthtomorrow

the

you’re in

is developing the

You need for