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

Workers Compensation outlier identification

September 10, 2020

Leading US Insurer

Problem Statement

  • The $ impact of medical provider fraud on US Insurers is enormous
  • For the majority of insurers, efforts on medical claim fraud identification tend to be concentrated on (and limited to) opposite ends of the spectrum: (a) rule-based and transaction-level reviews
    (b) SIU investigations
  • The sheer volume of invoices and the detail they contain, as well as the challenge of medical data can confound the process of manual claim review and allow fraudulent claims to filter through

Analytics Led Approach

  • An analytical solution to fraud identification that focuses on providers rather than transactions, and looks for patterns in provider behavior
  • The solution methodology is end-to-end: it ingests medical invoice data available with insurers, creates its own data assets and classifies outlier behavior using unsupervised machine learning techniques
  • Resourcing with functional, technical and clinical experts; high-touch execution; risks proactively identified & mitigated

Business Impact

  • Led to a larger (current) project encompassing a much larger span of data with a monthly refresh
  • Exploring bolt-on analyses (provider collusion, provider preference/ referral, flagging for clinical review
  • Delivered on-spec, on-time & with highly positive feedback
  • Strong buy-in from Client Analytics and SIU organizations

Critical Success Factors

  • Identified ~600 outliers among Company’s regular trading partners meeting conservative floor criteria
  • Identified ~$8+ MM in anomalous claims (from abovementioned ~600 outliers alone, closed claims alone)

    3AI Trending Articles

  • Mindtree achieves Application Development Partner Specialization in the Google Cloud Partner Advantage Program

    Mindtree on Monday announced that it has achieved the Application Development Partner Specialization in the Google Cloud Partner Advantage Program Technology services company Mindtree on Monday announced that it has achieved the Application Development Partner Specialization in the Google Cloud Partner Advantage Program. “This specialization highlights Mindtree’s expertise and success in building customer solutions in […]

  • Which Startup Ecosystem Attracted Higher Investments in 2020? – Bangalore or Delhi NCR

    Bengaluru continues to be ahead of Delhi NCR in terms of total funding raised by startups located in these cities The pandemic saw funding across the top startup hubs like Delhi NCR and Bengaluru drying up But both cities gave the country a steady influx of unicorns in 2020, keeping the interest of investors alive […]

  • Cloud Neutrality

    A multibillion-dollar, privately-owned infrastructure is now essential to the modern internet economy. That should freak you out. WE SPENT A lot of years talking about net neutrality—the idea that the companies that provide access to the internet shouldn’t unfairly block, slow down, or otherwise interfere with traffic even if that traffic competes with their services. But there’s […]

  • Data Science redefines Consulting to transform Digital Business Model

    Consulting firms the world over, are looking to develop competencies that would create a definite competitive advantage for them in the market. The consulting sector is no longer immune to disruptive technologies that have significantly influenced other digital-enabled businesses and is flooded with new players having a non-traditional approach toward consulting. Globally, companies seeking a […]