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Preethi MBA PPT - PDF - 20240422 - 000700 - 0000
Preethi MBA PPT - PDF - 20240422 - 000700 - 0000
• Fraud detection refers to the process of monitoring transactions and customer behavior to pinpoint
and fight fraudulent activities. It is usually a central part of a firm's loose prevention strategy and
sometimes forms a part of its wider anti-money laundering (AML) compliance processes.
• When fraud detection and its related functions are integrated into a wider AML framework, the
combination is sometimes referred to as fraud and anti-money laundering (FRAML).
• Detecting and preventing fraud in healthcare claims is therefore a critical component in ensuring
the sustainability and effectiveness of healthcare systems globally.
• The consequences of health care fraud are profound, extending beyond financial losses. Fraudulent
activities compromise patient care, erode public trust, and inflate the overall cost of healthcare
services.
• Fraud detection in healthcare claims is a critical aspect of the health care industry, aiming to identify
and prevent fraudulent activities that may lead to financial losses and compromise the quality of
patient care.
COMPANY PROFILE
•Carelon Global Solutions, a healthcare services company formerly known as Legato Health Technologies, intends to hire 3,000 people across various levels in
2023. The company — which began operations in India in 2017 — currently employs more than 18,000 people across Hyderabad, Gurugram, and Bengaluru.
•“Legato has evolved from an outsourcing center to a strategy and innovation hub, delivering whole health for its parent company, Elevance Health. As a new
brand,
Carelon’s main objective is to improve the health of the healthcare system,” noted Rajat Puri, COO, Carelon and President, Carelon Global Solutions.
•The transition is designed to transform healthcare operations through digital means and enhance the overall consumer experience, he toldbusiness line.
Elevance Health
is a health insurance service provider based in the United States, with revenues of $156 billion in 2022.According to the company, a lot of emphasis is put on
developing
mobile applications in India. “The main app for our parent companies, such as Sydney Health, and for our members is an app that is developed out of India by
•The transition is designed to transform healthcare operations through digital means and enhance the overall consumer experience, he toldbusiness line.
Elevance Health is a health insurance service provider based in the United States, with revenues of $156 billion in 2022.According to the company, a lot of
emphasis is put on developing mobile applications in India. “The main app for our parent companies, such as Sydney Health, and for our members is an app that
is developed out of India by Legato/Carelon Solutions.”
VISION
To be the trusted partner that makes better health possible. We come to work with
bold, big-picture ambitions: to empower a healthcare ecosystem for all.
For us, that means equipping health plans, health systems, employers, life
sciences, government agencies, and developers with premier, digital-first solutions
that make whole health easier to achieve across the health system —
from individuals and clinicians to care advocates and communities.
RESEARCH METHODOLOGY:
•To study about fraud detection and its significance in health insurance
claims.
• Health care management science 11, 275-287, (2008): Fraud and abuse have led to
significance additional expense in the health care system of the United States.
• Journal of Health Informatics in Africa 6 (2), 64-73, (2019): This research developed
a Fraud Detection System for National Health Insurance Scheme (NHIS) in Nigeria.
DATA COLLECTION
PRIMARY DATA:
The primary data will be collected through questionnaire and
interacting with employees of insurance agencies.
SECONDARY DATA:
• Sampling plan
• Sampling method
Simple random method will be undertaken for collection of data from the respondents.
• Sample size/Unit
PLAN OF ANALYSIS
To bring out the results of the study the data presented in the form of graphs, charts and figures with people
• The study is limited for fraud detection in health insurance claims in Bangalore.
CHAPTER-01- INTRODUCTION
CHAPTER-02- COMPANY
PROFILE CHAPTER-03-
RESEARCH DESIGN
SUGGESTIONS BIBLIOGRAPHY
ANNEXURE
TABLE NO. 4.13
Yes 23 76.7%
No 7 23.3%
TOTAL 30 100%
ANALYSIS
From the above data it is analyzed that out of 30 employees, there are 23 employees who states yes that is
76.7%, 7 employee who states no that is 23.3, for saying technology can be useful for identifying fraud.
CHART NO. 4.13
INTERPRETATION
From the above graph it is observed that majority of the employees at Carelon Global Solution
states YES and 2nd most states NO for identifying fraud using new technology.
TABLE NO. 4.14
News 7 23.3%
Articles 10 33.3%
Government 11 36.7%
Websites
Industry Report 2 6.7%
TOTAL 30 100%
ANALYSIS
From the above data it is analyzed that out of 30 employees, there are 7 employees who states news that is 23.3%, 10
employee states articles that is 33.3%, 11 employee who states government websites that is 36.7%, 2 employees who states
industry report that is 6.7%.
CHART NO. 4.14
10.00%
5.00% 6.70%
0.00%
0 0.5 1 3.5 4 4.5
1.5 2 2.5 3 RESOURCE TO
IDENTIDY FRAUD
INTERPRETATION
From the above graph it is observed that majority of the employees at Carelon Global Solution states articles and 2nd most is
government websites as the resources for identifying fraud.
FINDINGS
In conclusion, the findings from the analysis underscore the importance of proactive
measures in addressing health insurance fraud within Carelon Global Solution. By
implementing a comprehensive strategy that includes enhanced training programs,
investment in technology, streamlined reporting mechanisms, and regulatory
compliance, the organization can significantly
improve its fraud detection and prevention capabilities. Additionally, fostering
interdepartmental collaboration, maintaining continuous education and awareness
initiatives, and prioritizing data security are crucial steps towards creating a robust anti-
fraud environment.
Furthermore, establishing partnerships with government agencies and
prioritizing continuous improvement will ensure that Carelon Global Solution
remains vigilant and adaptable in the face of evolving fraud threats. By
embracing these recommendations, the organization can safeguard its financial
resources, protect its reputation, and uphold the trust of its stakeholders.
Ultimately, a proactive approach to combating health insurance fraud will contribute to
the long-term sustainability and success of Carelon Global Solution in the healthcare
industry.
BIBLIOGRAPHY
2. Aspen Health Law Center · (1998) · The HHS, DOJ, state Medicaid Fraud
Control Units, even the FBI is on the case.