Claim Fraud Uncovered
How data analytics and field audits exposed fraudulent health insurance claims
Exposing Insurance Claim Fraud in a Health Insurance Provider
A major health insurance provider noticed a surge in high-value claims with questionable documentation. Concerned about potential organized fraud, they enlisted our team to investigate and safeguard their operations.
Client Background
A growing health insurance provider facing a surge in suspicious claims and rising operational losses.
Client :
National Health Insurance Company
Industry :
Insurance
Region :
Middle East
Customers :
700,000 policyholders
Total revenue :
$600 million annually
Challenges
The insurer struggled to differentiate between genuine and fraudulent claims due to the sheer volume and complexity of medical documentation. Manual reviews were time-consuming and prone to error, leading to rising payouts and operational strain.
Our Approach
Leveraging data analytics, AI tools, and expert insights to uncover irregularities and validate claim authenticity.
AI Analysis
Automated claim data analysis using AI-driven tools
01
Record Matching
Cross-referenced claims with medical provider records
02
03
Targeted Audits
Conducted targeted audits on suspicious claims
04
Expert Review
Engaged with medical professionals for expert opinions
Solution
Deploying intelligent audit techniques and expert collaboration to identify and prevent fraudulent medical claims.
Uncovered a network of fraudulent clinics submitting fake claims
Recovered over $3 million in improper payouts
Introduced automated red-flag systems for early fraud detection
Updated policyholder and provider onboarding processes
Business Impact
The client achieved substantial cost savings, improved claim processing efficiency, and strengthened relationships with genuine policyholders and providers. The new anti-fraud measures set a benchmark for industry best practices.
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