India's largest platform for AI & Analytics leaders, professionals & aspirants

Sign in

India's largest platform for AI & Analytics leaders, professionals & aspirants

3AI Digital Library

Claims Fraud Detection

August 15, 2020

Leading Global P&C Insurance Company

Problem Statement

  • Customers’ current SIU was geared towards proactively identifying and detecting claimant related frauds.
  • Fraud related to medical provider were proving to be difficult to identify and work upon
  • Customer had to rely on referrals from regulatory and industry bodies to identify suspect cases and wanted to explore ways and means to pro-actively identify provider fraud through statistical means

Analytics Led Approach

  • Framework on claims fraud detection was developed to identify the potential losses due to fraud or suspect claims and thereby helped to  reduce claims leakage to a great extent
  • Given are high level process steps which were followed
    • Sensitive data encryption
    • Load the data from multiple sources
    • Data cleansing
    • Data transformation
    • Business Significant variables deduction
    • Distribution analysis
    • Correlation analysis
    • Multi- dimensional Analysis Fraud analysis through data profiling

Business Impact

  • An analytical solution that focuses on providers rather than transactions, and looks for patterns in provider behavior was developed
  • The solution methodology was end-to-end: ingesting medical invoice data, creating its own data assets and classifying outlier behavior using unsupervised machine learning techniques
  • Solution outcomes were tangible and allow self-serve configuration of business rules.
  • Recommendations can readily be evaluated by follow-up investigation and $ business benefits are easy to estimate and establish

Critical Success Factors

  • Key suspect indicators and patterns were identified which indicated possible provider frauds
  • Identified $ 6.4 million was charged for medical bills by suspect medical Providers

    3AI Trending Articles

  • MassMutual GCC to come up in Hyderabad

    With 300+ associates and leadership in all functional areas already on-board, MassMutual India is actively hiring for multiple roles in the areas of application development and support, cloud engineering, data science, and analytics, said a statement from the minister’s office. Massachusetts Mutual Life Insurance Company, a US-based leading life insurer, Monday announced opening of a […]

  • Cybersecurity To Remain Hot In The New Year

    Despite a pandemic that raged around the globe for the better part of the year, the cybersecurity market retained investor interest in 2020 and many in the sector expect next year to be no different. “Security is a red hot sector with more and more money pouring into it,” said Andrew Atherton, managing director at Union Square […]

  • 2 Transportation related Stocks leading the New Wave with AI

    Technology is changing our world, with results visible in real time. If you grew up in the 1980s, watching reruns of Star Trek, think for a moment about fantastic gadgets that have walked off the screen and into our lives: portable communicators, portable computers, voice-activated systems, to name just a few. Scotty once even automated […]

  • Cybersecurity Challenges: Fourth Greatest Danger to Global Economy

    The 2021 World Economic Forum (WEF) Global Risk Report, used for over a decade by organizations around the world as a risk assessment tool, has named “cybersecurity challenges” as the fourth most pressing danger to the global economy. The ranking is determined by responses to a survey conducted among various stakeholders and organizations affiliated with […]