iPera is a medical industry leading innovation that brings seamless experience in the day to day interaction between the insurers, medical health service providers and patients. iPera is a medical claims switch that routes patient medical claims and invoices from medical service providers to the insurers, with real time transparency to members on limits utilization.

iPera enables medical providers to digitally access patients’ health insurance details when they visit to seek treatment. This system enables the service providers to retrieve information on eligibility of patients, view their membership limit balances, access levels, inclusions and exclusions.  iPera automatically switches the claims and other pertinent information to the insurers information management systems in real-time.

iPera is a highly efficient and powerful interface whose wide range of capabilities facilitates easy, safe and secure transmission of patient claims and invoices between medical provider facilities and insurance firms. Also a resource tool for patients, containing information on which health facilities their insurance service providers are partnering with where they can access the required healthcare.

iPera is a very strong weapon against fraud, it is integrated in iPera cards, with the owner’s biometrics details therein ensuring accurate patient recognition.

It is a web portal platform and it is cloud-based. This improves its security aspects using SSL certification and data encryption, ensuring that all information processed is safe and secure. It is simple to use and has a user friendly interface. Build on innovative web technological standards on distributed system and integrated to Mobile computing.

iPera brings very high levels of accuracy and openness in the management of data, and this guarantees  drastic reduction in incidences of fraud. It enhances transparency to the whole process by allowing medical facilities a real-time view of claims and invoices being processed by the insurers, thereby eliminating possibility of erroneous entries passing unnoticed. iPera also reduces dramatically the time spent in claims processing, thus aiding in cost cutting and enhanced service delivery.

Global studies show that only around a quarter of insurance customers trust their provider. This means three out of four do not think their insurer will live up to their promises. This deep level of mistrust may be as a result of consumers falling victim to fraudulent schemes by players in the industry, perceptions of being shortchanged in their time of need, or sheer disdain of the perceived opaque nature of the medical industry. iPera will go a long way in enhancing transparency and efficiency in the health insurance sector, a factor that is bound to improve customer satisfaction and raise the already low consumer confidence levels.

IPERA objectives

iPera, a powerful platform that packs cutting edge capabilities whose impact will propel health insurance sector to higher and more efficient levels of service delivery.   The deployment of iPera in the health insurance sector will achieve two main objectives :

  1. Fraud detection, Management and transparency
  2. Efficiency

A: Fraud detection

iPera addresses the fraud problem very solidly. It integrates information in hospital and insurers systems in such a way that it provides transparency to insurances, medical providers, Members and all these parties having accessible to secure unified information.

With patient information and biometric details packaged in personalized iPera cards, all parties are able to conclusively and accurately determine identities of persons served in hospitals. This ensures fraud incidences such as identity theft and membership substitution are easily detected.

Fraud manifests itself in various forms that are curbed by iPera:

  • Up coding: intentional use of a higher-paying code on the claim form for a patient to fraudulently reflect the use of a more expensive procedure, device or medicine than was actually used or was necessary
  • Over-servicing: situations where patients  visit  their  doctors more  regularly than they  need ,  and having a perception that it  as  a    free service.   Doctors  are  also  processing  more patients  to  increase  their   revenue,    sometimes  suggesting  further  checkups  that  may not be essential.
  • Fee splitting: it is a practice where a medical professional splits their professional fees for a referral. This is done to ensure the fees charged for any consultation or service falls below the prescribed limit set by the insurer.
  • Membership  substitution: involves replacing  the initial  beneficiary  registered  at  the  point of securing  cover  in  order  to  benefit  from  the  cover  e.g.  substituting  a  member  of  the family  who  was  not  under  the  insurance  cover  due  to  increased  vulnerability  of  the unregistered member of the family relative to the ones on the cover.
  • Waving copays and deductibles: where waivers  are  offered  to  beneficiaries  in  cost-sharing  arrangements  and  higher  fee  is  claimed  from  insurers  or  the  deterrents  to access service is waived.
  • Dual membership: membership to two or more schemes
  • Merchandise substitution: prescriptions are made for specific medicinal drugs but substitute goods e.g.  diapers are given to beneficiaries instead and claims made.
  • Phantom Billing: This is billing for services or office visits that never occurred, commonly involves the medical officers per se.
  • Medical Identity Theft: using other person’s insurance card or number without their knowledge to falsely obtain medical services.

iPera’s ability to integrate patient membership information in insurers systems to patient information in systems of  all hospitals goes a long way in stopping fraud before it happens. By using finger biometric details as well as iPera card authentication to accurately identify patients, this system ensures medical services and accruing claims are properly attributed to the correct persons.

iPera allows medical facilities a real-time view of claims and invoices being processed by insurers, thus enhancing transparency to the whole process and reducing chances of data tampering passing unnoticed. This will translate to lesser incidences of fraud occurring.

B:Efficiency

(i)         Ease of use and reliability:

iPera is web-based and hosted in the cloud. This ensures it is accessible from anywhere any time by authorized persons as long there is available internet.

(ii)        Time-saving:

With invoices and claims generated in hospitals being submitted to the insurers in real-time, the insurers will be better placed to process the claims in good time to avoid unnecessary delays.

(iii)      Accuracy:

By enabling an uninterrupted flow of digital information between the hospitals and insurers, the accuracy of the data transmitted from one side to the other is ensured. Insurers are in a position to easily establish in real-time all financial commitments arising from submitted invoices and claims, thus creating more efficiency and accuracy in their budget making processes.ie. Availability of information in real-time will help the insurers plan their budgets with more accuracy both in time and finances. Biometric details obtained from the patient will be fed into iPera after which it will be personalized into a membership smart card. This will eliminate any incidences of fraud arising out of wrong identification.