THE CHALLENGE
Health insurance is prohibitively expensive. One major cause of this is fraud. Insurers do not have the capabilities to capture fraud (estimates accounting for >50% of payout); and the nature of markets prohibits advanced technological solutions. Thus, the natural choice is to cover such claims while raising premiums.
HEALTHCARE FRAUD
Healthcare fraud costs insurance companies anywhere from 15~40% of annual revenues every year. This is particularly prevalent in the developing world with fragmented healthcare connectivity. We work very closely with insurance companies aligning with their data collection practices and developing power analytics that works with substandard data collection practices. With our algorithms in anomaly detection combined with our in-house medical expertise, we are able to pick up a wide variety of discrepancies and bring them to notice using insightful dashboards for the leaderships of the insurance industry.
Many treatment costs are well over the baseline cost for that particular clinic and/or region with no supporting basis
Abnormal Fees
The prescribed drugs or diagnostic tests are not suitable for the treatment defined and/or over-treatment
Abnormal Costs
Those likely use their benefits for multiple people due to the unreasonable number and type of claims