The problem

One of the most important problems of the insurance industry is fraud which causes substantial losses. The US National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year. A conservative estimate is 3% of total health care expenditures, while some government and law enforcement agencies place the loss as high as 10% of annual health outlay, which could mean more than $300 billion. The FY 2020 Medicare FFS estimated improper payment rate is 6.27%, representing $25.74 billion in improper payments. The FY 2020 national Medicaid improper payment rate estimate is 21.36%, representing $86.49 billion in improper payments.

The purpose

Detect and eradicate health insurance fraud

The solution

An AI-based tool that assesses all claims, and flags possible fraudulent claims or wasteful, prior to reimbursement.

The benefit

The benefits are the following:

  • administrative cost reduction
  • operational cost reduction
  • inspection cost minimization
  • expenditure control
  • claims prediction
  • strategic advantage in pricing
  • strategic advantage in underwriting
  • ultra-high ROI