Insurance companies are investing in fraud detection solutions to reduce losses arising due to fraudulent claims. In the context of healthcare claims, analyzing historical claims data needs to accompany an analysis of billing, provider details such as location, speciality and ownership, patient codes and diagnosis from a social network analysis lens. This allows the insurers in understanding both the salient mechanisms of fraud and the subtle mechanisms such as involving provider fraud.
This solution takes into account the relationships between providers, patients, and payers to discover if any patterns exist. Additionally it studies the type of device used to submit claims, and the IP address from which the claims are submitted and processed. By augmenting this with third-party data sources such as public records, legal documents, third-party audit reports, and news reports, this solution can be used to identify potential fraudulent activities, such as a provider being involved in lawsuits or having a history of fraudulent activities.
Implementing this solution reduces financial losses by detecting fraud early and accurately. It also helps the insurance company in improving the efficiency of claim processing by reducing the time and effort needed from expert fraud investigators. In addition, this solution can also ensure compliance in claims submission and processing, helping you in protecting the best interests of your policy holders and improving their trust and satisfaction.
* Values are approximates arrived at based on earlier experience and/or existing literature. Contact us to find out how you can measure the ROI on this solution for your business