Our health tools

Introducing Lorica Health

Lorica Health was established in 2011 as CMC Insurance Solutions, a commercial spin off resulting from research conducted by CMCRC. The company analyses more than two thirds of Australia’s private health insurance claims and works with  Australian government agencies responsible for ensuring the integrity of end to end public health programs.

Lorica Health’s products are the culmination of multi-year, multi-million-dollar investments in R&D, along with extensive industry testing led by an experienced, multidisciplinary team of data scientists, programmers and health experts.

These globally applicable SaaS products apply advanced analytics to healthcare data to target fraud, abuse, waste, and errors. The products are:

HIBIS (Health Insurance Business Intelligence System) – a fraud, abuse and waste detection product. Standing at the forefront of compliance and payment integrity operations, HIBIS allows healthcare payers to accurately and efficiently prevent and recover inappropriate claiming.

• Process claims through a high-performance rules engine
• Detect billing anomalies
• Navigate claims and related alerts information using context-specific and clear explanations
• Apply supervised machine learning to a payer's case management history, guiding users towards high value alerts
• Support analyst workflow to recover incorrect payments, while capturing actions and results
• Deliver flexible and comprehensive management reports.

I+Plus – a platform offering rich and responsive analysis in support of clinical comparison, hospital negotiation, benchmarking, contracting and the management of health service delivery.

Born out of health data science research, I+Plus is delivers provider performance information derived from the application of clinical measures of quality, value and safety, as well as claims scoring and predictive modelling capabilities.

Key benefits are:

• Support of hospital contract negotiations by benchmarking quality and performance metrics
• Claims analysis to enable the investigation of high-priority issues
• Provider referral and readmission analysis as it pertains to reducing or eliminating low quality admissions, unnecessary readmissions and low-value services or procedures.

I+Plus has been developed to support filtering of data by patient characteristics, treatments, DRGs, hospital peer groups and other factors. This lets Lorica Health present ‘like with like’ comparisons’.

Gamma – a platform for identifying and investigating inappropriate healthcare claiming patterns. Where HIBIS focuses on individual claims, Gamma extends this by using a risk-scoring approach to evaluate the totality of provider claiming behaviour.

Gamma is Lorica Health’s next-generation analytics tool. It uses a flexible analytical framework to assess provider claiming trends across a range of behavioural indicators. The platform can be adapted to monitor a range of different behaviours, such as non-provision or misrepresentation of services or the delivery of medically unnecessary procedures. It can also be applied to monitor patterns at any level – e.g. provider, practice or member.

NeMo (Negotiation Module) – a platform that supports hospital and payer contract negotiations. NeMo provides your negotiation teams with rapid, rich and granular insights into hospital pricing and quality, together with workflow support to ensure a streamlined, data-driven negotiation process.

The key benefits are:

• Health intelligence on relative provider value, based on historical claims data
• Supporting evidence to compare peer hospitals
• Clear visualisation of peer group comparison on price and quality.