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

Sign in

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

3AI Digital Library

Claims Fraud Detection

3AI 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

  • IIT Kanpur introduces Master’s programs in Cybersecurity

    IIT Kanpur has introduced three new cybersecurity postgraduate programs with intent to to address the need of cybersecurity personnel by ensuring training of dedicated and highly skilled manpower.   With a view to meet the shortfall in trained and skilled cybersecurity personnel in the country, the Indian Institute of Technology, Kanpur has decided to introduce […]

  • Unlocking Synergy: Combining Computer Vision, NLP, and Deep Learning for Automated Process Discovery & Process Intelligence

    Featured Article: Author: Anurag Upadhyay, Accenture Introduction: In today’s dynamic business landscape, organizations face an ever-increasing demand for efficiency, innovation, and competitiveness. To meet these challenges head-on, businesses are turning to cutting-edge technologies that can revolutionize how they understand, optimize, and manage their operations. Among these transformative technologies, the fusion of Computer Vision, Natural Language […]

  • Cloud4C and Google Cloud to build CoE for SAP and Anthos

    The partnership aims to enable enterprises to accelerate their digital transformation journey on the cloud. Cloud4C, a cloud managed services provider, is collaborating with Google Cloud to build a Centre of Excellence (CoE) for SAP and Anthos by Google Cloud. The center of excellence (CoE) will equip businesses with capabilities to modernize mission critical IT infrastructure and applications, while […]

  • Upside AI to use ML to make Fundamental Investment Decisions

    The pandemic has made humans more dependent on technology, be it for working, shopping and now even for investing. Upside AI — a SEBI registered Portfolio Management Service (PMS) is among the first funds in India to use machine learning to make fundamental investment decisions. The technology-focused fund believes that the next Warren Buffett would […]