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Swiss Medical has grown to over 60,000 practitioners and 730,000 patientsin the past 18 years by providing extra services using a personalized plan.With over 2 million claims per month, a laborious and vulnerable paper-basedsystem for claims processing became inefficient. ILOG JRules was incorporatedinto Swiss Medical's automated system to unify business rules throughout SwissMedical's entities and to streamline its claims processing. With ILOG JRules,Swiss Medical is automating such functions as fraud detection, claimassignment and adjudication, and payment and settlement.
"ILOG has been instrumental in helping us implement our Claims ExcellenceManagement project," said Luciano Graffi, database administrator, applicationarchitecture and operations management, Swiss Medical Group. "This projectfocused on achieving short- and medium-term monetary gains by incorporating awide set of rules that span across the claims process. Using ILOG JRules tostandardize our claims process, we have reached our goals of becomingpaperless, eliminating process silos, and reducing fraud and abuse. Inaddition, the new system has enabled us to reduce claim costs and fraud by anestimated 30 percent, resulting in significant savings."
Automating the claims process and centrally maintaining and managing thebusiness rules with the utmost of transparency have made a significant impacton improving efficiency. With the previous system, conspiracy to defraudbetween medical students, practitioners, patients and internal personnel wasproblematic and difficult to control. Today, deception is avoided byelectronically processing claims using ILOG JRules and avoiding long-standingcontracts between the claims processor and the practitioner.
Prior to automating the system, fraudulent claims were not easilyidentified; this resulted in payment for procedures not covered under thegovernment's healthcare plan. Today, false claims are detected with ILOGJRules and are efficiently processed by determining what percentage of eachprocedure is covered by the government and which portion can be paid for bythe Swiss Medical Group plan.
ILOG has consistently built on its history of product innovation to makeit one of the industry's leading providers of business rule management systems(BRMS). Forrester Research has recognized ILOG as a resounding leader inBusiness rules platforms, including the sole leader in rules platforms for.NET, a leader in business rule platforms for Java, for business analysts andfor overall feature sets. Customers of ILOG's award-winning BRMS productsinclude eBay, Equifax, Grupo Santander, Travelocity, Visa and many otherleading Global 2000 companies and governments worldwide. ILOG's BRMS productline includes ILOG JRules(R), ILOG Rules for .NET(R) and ILOG Rules forCobol(R) To learn more about ILOG's BRMS products, please visithttp://www.ilog.com/products/businessrules.
About ILOG
ILOG delivers software and services that empower customers to make betterdecisions faster and manage change and complexity. Over 3,000 corporations andmore than 465 leading software vendors rely on ILOG's market-leading businessrule management system (BRMS), supply chain planning and schedulingapplications, as well as its optimization and visualization softwarecomponents, to achieve dramatic returns on investment, create market-definingproducts and services, and sharpen their competitive edge. ILOG was founded in1987 and employs more than 850 people worldwide. For more information, pleasevisit http://www.ilog.com.
ILOG, ILOG JRules and ILOG Rules for .NET are registered trademarks ofILOG S.A. and ILOG, Inc. All other company and product names are trademarks oftheir respective owners.
SOURCE ILOG
