5 Managing risk and compliance

Question 1

Please can you tell us about a time when you have dealt with RCA based situation for a customer/the team and have taken ownership to resolve the situation?

Answer 1

Situation

When I was a BG manager in late 2022, I worked with incidents and counter fraud in using complaints and claims data to identify a Greek based corporate group who had suspicious claim activity associated with them. I was initially alerted to this pattern in seeing several of my case handlers handling complaints associated with this group, and one in particular that involved potentially fraudulent activity.

Task/objective

• The most pressing initial task was to establish whether there was any suspicious activity wholistically across the group, or whether the series of cases was more co-incidental. The substance – or ‘what’ – of the issue first needed to be clarified
• If there was clear evidence on a complaint level to show concern, this could then be raised firstly with counter-fraud to get a claims perspective, and then potentially with more senior management (i.e. acc manager, heads of for EEA region) to establish what action to potentially take.

Actions

• First stage

*I also used knowledge I’d previously gained, about creating specific Respond searches, to associate the groups specific ID with a complaint search. In setting up this search, it turned out there was a large number of active and open complaints with this particular group. This, alongside 5 claims that had also been associated with this group for suspicious activity, mean’t that we had enough data and evidence to at least suspect a wider-pattern.
*Intially, we reported this to claims fraud team
*They were potentially exploiting a lower limit pay ruling that was in place in the region for select pharmacy claims.
Second stage

• was to make relevant stakeholders aware of the issues, and report to the relevant subject matter experts on the amount of active (and closed complaints) that we had for this associated group.

Results

*The account manager themselves also had a conversation with the group secetary around the trend, and 2 members were actively lapsed from the policy
 Follow-up results
o This data and information then fed directly into a new initiative used by Call net, our Service partner in the area, leading to a 100% audit sheet approach (previously claims under 200 GBP had not been audited).
o As a result of spotting this complaint trend, this audit sheeting approach has led to approximately savings for Jan 23 – Aug 23 so far stand at 287.5k EUROS vs €105.6k EUROS same time last year

Question 2

Tell us about a piece of work you delivered quicker than expected.