ClaimsGator for Insurance (Property & Casualty, Healthcare)
In January 2009, two Chicago-area doctors were charged in cases of health-care fraud. They received almost $14M in reimbursements from insurers on treatment that was never performed. Allegedly the doctors acquired private healthcare information on certain patients and hired people as 'billers' to submit claims to Medicare and other insurers.
In another case from March 2008, the New York District attorney reported a fraud ring that had cheated insurers out of $6M. The fraud ring comprised 13 persons, including six medical professionals, and a team of runners. It would stage accidents, and the "patients" would be sent to a medical mill where a team of therapists prescribed unnecessary tests and diagnosed soft tissue injuries requiring purchase of expensive medical supplies.
Why ClaimsGator?
In its April 2010 report, Gartner identified the top 10 technology initiatives with the best return on investment for an insurer. These are listed below.
- Modern policy and claims management systems,
- Web services and SOA tools,
- Business intelligence and analytics,
- Predictive modeling tools,
- Advanced fraud detection solutions,
- Web 2.0 and social networking technology,
- Product development and configuration solutions,
- BPM solutions, including workflow and rule engines,
- Portal and Internet technologies,
- Mobile devices/technologies,
How does ClaimsGator capture the above type of fraud?
ClaimsGator is an auditing tool that reads in the claims received by the insurer and identifies aberrations in behavior by each entity that sits between the insurer and the claimant. These entities can be the medical professional, the auto-body shop, or even the adjuster appointed to validate the claim.
The technology incorporates a combination of advanced analytics and a unique web interface for exploratory analysis.
There three categories of fraud that we identify.
- Non-existent procedures or customers,
- Up-coded service procedures,
- Collusion among different service providers.
ClaimsGator uses artificial intelligence techniques and multivariate analysis to detect deviations in the partnersÂ’ behavior. The chart graphically represents the technique of deviation detection. The 'norm' is the center of the grouped claimants. The further a specific claimant is from the center, the higher the likelihood for fraud.ClaimsGator also offers business process integration via customizable modules for case management, investigation workflow management and accounting. This helps ensure that not only do you identify who is cheating you, but you also have the support to initiate recoveries.