Daisy's Investigative Workflow Supports Insurance Decision-Making

Fighting fraud has become an increasingly demanding battle – especially as insurers are pressured to provide faster and better service. With resources stretched thin, Daisy aims to provide a better investigative and claims management experience.

Daisy’s integrated suite of solutions detects fraud, automates claims processing, and underwrites risk - delivering incremental value and verifiable financial results. With a workflow that streamlines and consolidates internal systems, insurers are better positioned to achieve overall business objectives and deliver on their organizational mission.

This blog post will provide a high-level overview of Daisy’s end-to-end investigative workflow and explore how the capabilities are supporting investigative efforts and providing considerable value.

End-to-End Investigative Workflow

Daisy’s end-to-end investigative experience supports suspicion identification through to case investigation and claims processing. Hosted via an agile and dynamic online portal, the system offers insurers actionable recommendations that enable impactful decision-making.

With the centralization of claims data and explainable recommendations insurers can trust, insurers are empowered to take on only the highest value tasks – in turn, realizing significant time and labour savings.

Insurance Portal Capabilities

The Daisy workflow begins with suspicion identification. Investigators can access an alerts dashboard via the online portal. The dashboard identifies all suspicious claims or entities, which are presented hierarchically in terms of their Daisy score and are filtered using a score threshold chosen by each organization.

Importantly, each alert comes with a link to an alert summary that provides a comprehensive view of each entity to aid investigators and analysts in deciding if an alert should be accepted for investigation or not. The summary also explains why an entity is suspicious via a suspicion summary - building trust in the system capabilities by offering the rationale behind each decision.

Investigators are now able to accept or deny alerts for investigation. When an alert is accepted, investigators are prompted to create a case. Managers can assign new cases to investigators on their team, who can utilize the portal to log details as progress is made in the investigation. Importantly, Daisy’s recommendations can be leveraged to decide the appropriate course of action for the investigation, such as contacting any individuals involved to validate information. Based on the outcome of the actions taken, investigators can opt to close a case at any time.

To get a granular view into the Daisy portal, download our latest whitepaper.

Solutions Supported by the Daisy Workflow

Primarily, the Daisy system identifies fraud by identifying the Halo Effect – i.e., outliers – in claims data. With Daisy uncovering claims and entities recommended for investigation, insurers can now identify all suspicious behaviour in their claims data to proactively eliminate fraud before costly payments are made. The system capabilities also enable insurers to recoup payments by finding previously undetected fraud with great speed.

The Daisy workflow also supports claims automation and straight-through processing by making autonomous claim payment and fraud avoidance decisions. The Daisy system is applied to review claims that fall below the threshold for investigation and provide recommendations for auto-pay, auto-deny, investigation for potential fraud, waste, or abuse, accelerated human review, and full manual adjudication. Should organizations choose to forego fully autonomous review, they can select a level of autonomy that best fits their needs and level of comfort – e.g., tiered human review.

Finally, the Daisy system aligns pricing with risk while minimizing fraud, waste, and abuse at the underwriting stage. Daisy applies peer analysis to underwriting data and looks at the historical claims of peers to identify outliers and high-risk individuals. Daisy will provide a risk or underwriting index to create an appropriate premium for the policy – high risk individuals are assigned a higher premium to cover expected future claims.

The system provides explainability for all recommendations, meaning insurers can feel confident at every stage as they leverage system recommendations.

Daisy’s investigative platform offers specific, actionable recommendations – enabling insurers to make the most impactful investigative decisions possible to achieve their overarching business objectives.

With solutions for fraud detection, claims automation, and underwriting, insurers can eliminate fraud, waste, and abuse and minimize human touch in claims processing. In turn, insurers will discover an improved case management and investigative experience – making a tough job easier.