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

  • Changing face of Algorithms

    In the age of Big Data, algorithms give companies a competitive advantage. Today’s most important technology companies all have algorithmic intelligence built into the core of their product: Google Search, Facebook News Feed, Amazon’s and Netflix’s recommendation engines. “Data is inherently dumb,” Peter Sondergaard, senior vice president at Gartner and global head of Research, said […]

  • Redefining Business with Algorithms

    Algorithms will not only drive scores of business processes, but also build other algorithms, much as robots can build other robots. And rather than using apps, future users’ lives will revolve around cloud-based agents enabled by algorithms. Gartner expects that by 2020, smart agents will facilitate 40% of all digital interactions. Organizations will license, trade, […]

  • Blockchain and IoT gives end-to-end visibility to Stakeholders in a Supply Chain

    While IoT sensors help track the movement and quality of products, blockchain’s distributed ledger gives multiple entities joint control over shared information . Covid concentrated attention on supply chains like never before as the pandemic caused massive disruptions. Companies started looking deeper into the roots of their supplies, going further back than their immediate vendors. […]

  • Reimagine Business Strategy & Operating Models with AI : The CXO’s Playbook

    Author: Sameer Dhanrajani, CEO at AIQRATE advisory & consulting | AI advisor, business builder | Author | Speaker |Columnist| President at 3AI | Ex-CSO: Fractal, Global Business Leader: Cognizant, Country Head: Fidelity National Financial AlphaGo caused a stir by defeating 18-time world champion Lee Sedol in Go, a game thought to be impenetrable by AI […]