AI and the fight against insurance fraud

Dan Donovan, Vice President of Customer Success & Solutions Consulting for the Americas at Shift Technology, said:

“Data is still siled in most telecom operators’ traditional billing systems and even the newest modern billing systems. Data is vast and often distributed and siled.

“The challenge is to have all the data in one place and be able to examine that data to identify patterns that could predict potential fraudulent claims. Identify what the odd signal is that makes it different.It’s a clean and worthy claim,” Donovan explained.

Shift is a technology provider that uses artificial intelligence (AI) to automate and optimize insurance business processes. Based in Paris, the company has offices around the world, including Toronto and Boston. Clients include major insurers in property and casualty (P&C), travel, health, workers’ compensation and life insurance.

This year, Shift partnered with the Équité Association, an independent nonprofit dedicated to preventing insurance fraud, to build a nationwide fraud detection system using AI. The project is a first for a Canadian property and casualty insurer.

read more: Équité Association, Shift Technology Partners Create AI-Powered Fraud Detection Platform

Tools like Shift’s fraudulent claim detection allow operators to extend this process and centralize data, but many still use manual processes and are already overloaded with customer service. relies on a billing agent who is often Donovan noted that the human factor can make claims pipelines more prone to leaks.

“Some people do [fraud detection] Better than others, some are savvy about scams. Different levels of experience and knowledge are involved. In its current state, the process really either succeeds or fails,” says Donovan.

Fraud detection

Many cases of insurance claims fraud are often opportunistic, with individuals inflating injuries and property damage to take advantage of the incident and make more money. For example, one of the most common types of billing fraud involves tiered losses.

“Carriers may see a lot of what we call ‘paper accidents’. [the claimants] Sometimes we intentionally crash cars or cause these accidents on paper,” says Donovan. “Claims can run into tens of thousands of dollars for treatments that never actually occurred, for example.”

read more: IBC reveals the 5 most common types of fraud

These types of fraud can have a significant impact on overall premiums, Donovan added. As the technology around billing fraud detection has grown, so have the scams. One of the industry’s biggest concerns is how to stay ahead of scammers.

“Every time we make a change, every time we identify and detect fraud, they’re looking for another loophole,” Donovan says.

The “white box” approach

According to Donovan, Shift takes a “white box” approach when tackling claims fraud with clients, referring to software testing methods that evaluate the inner workings of code and programs. The main focus of white-box testing is determining whether the defined inputs produce the desired output.

“Many providers will ask for your data and generate output. ,” Donovan told Insurance Business. This flexibility allows Shift to foster close collaboration with clients and adapt to industry needs and trends.

“We work with customers who have different lines of business dealing with different types of fraud. If they mention a new fraud trend, we work with them to create scenarios to detect it.This process is constantly evolving,” explained Donovan. To do.

Addressing billing fraud also requires a holistic view of the carrier billing process. Amid the industry’s digital transformation, carriers are balancing human touch and automation.

“It’s not just about detecting fraud. It’s becoming more important for carriers to improve the customer experience as they digitize and automate the billing process,” says Donovan. “[Carriers ask]: “How can I get a level of peace of mind that my claim will be processed ‘smoothly’?” Working with a good fraud detection vendor that can ”

By automating certain tasks in the claims process, employees can spend more time on high-value tasks. It also helps level the playing field in a changing job market as experienced claims specialists age and gaps arise in agency knowledge.

“By automating [claim handling] Through AI and machine learning, new claims agents can make better decisions by providing insights that seasoned claims agents typically gain through experience,” said Donovan. says.

AI and the fight against insurance fraud

Source link AI and the fight against insurance fraud

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