Increased Fraud Recoveries and Avoidance

Daisy implemented its Fraud Detection solution for the dental line of business during this trial to meet our client’s objectives and to build a business case for enhancing fraud detection and avoidance capabilities.

• Daisy Fraud Detection: Automated AI-based fraud detection system that would identify potential fraud for both historical claims as well as in-process claims before adjudication was completed.

A typical Daisy implementation requires two months to onboard the client’s data and to work with the business operators to understand the client’s existing process and capabilities in claims processing. The client already had a set of fraud flags that were used for fraud detection and had historical labels for previous fraudulent claims and individuals. Over a six month period, Daisy delivered its system which included integrating the client’s flags with Daisy’s existing probabilistic rules. Predictive models using the client’s labels were autonomously deployed, fuzzy logic peer analysis of patients and providers was autonomously deployed, and social network analysis of all entities was autonomously deployed.

The client dedicated a single investigator to work with the Daisy system. The client was willing to retroactively seek repayment from dental providers through legal means.