Increased Fraud Recoveries and Avoidance
Large North American insurer increases fraud recoveries and investigative capabilities
Our client was the Canadian headquarters of one of North America’s largest insurance companies. This division was responsible for group health benefits claims for both individuals and group policies. Annual claims processed are in the billions of dollars.
The client was seeking to augment its fraud investigative capabilities with an AI system. Current fraud recoveries were less than the industry stated belief that 3% to 10% of all claims had some element of fraud or abuse. The first step to building an operational AI-based fraud detection capability was to assess the amount of fraud, waste and abuse that was detectable and recoverable or avoidable. Once the magnitude of the opportunity was understood, a business case could be developed to enhance existing capabilities. The client identified that Daisy’s AI platform for insurance could be a fit to achieve the project objectives and engaged Daisy in a trial.
- 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.
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.
The Daisy system applied to historical data discovered cases of new fraud that had not been previously investigated that one investigator was able to follow up on. Immediate recovery opportunity from these cases resulted in significant post-payment recovery and future fraud avoidance. Increasing the bandwidth of investigative effort resulted in significant annual fraud avoidance for one line of business.
183 Cases of New Fraud Found
$100K in Immediate Recovery
$1M in Future Fraud Avoidance
$10M in Fraud Avoidance
We’re delivering incremental value to our clients
A leading global insurer
Daisy’s solutions saved >$5M through auto-adjudication.
Green Shield Canada
One-third of the files opened in 2018 were as a result of information obtained from Daisy’s fraud detection system, accounting for 25% of Green Shield Canada’s total prevention and recoveries.