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America's Claims Executive Virtual Leadership Forum

Watch Industry Experts Discuss

The Use of New Technology in Fraud Detection and Mitigation

The ACE Leadership Forum is designed to cover the most critical issues facing claims and insurance executives from emerging risks to the evolving workforce to enriching the customer experience.

 

The discussion was focused on the adoption status of advanced analytical techniques using AI to evaluate claims for possible fraud. Additionally, the experts examined if new technologies can do a better job of identifying true positives to be referred to the special investigations unit. 

 

Points of discussion included:

  • What are some of the new tools to first identify claims for possible fraud?

  • What tools are currently available to SIUs for investigation?

    • Anything new and different?

Speakers:

  • Moderator:  Anand Shirur, Senior Vice President – Product Development - Klear.ai

  • Jessica Albano, SIU Unit Leader - Westfield

  • Frank Neugebauer, Senior Architect - Cincinnati Insurance Companies

  • Steve Robles, Assistant Chief Executive Officer - County of Los Angeles

  • Dennis Tierney, Senior Vice President, National Director of Workers’ Compensation Claims - Marsh

 
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Klear.ai

The Klear.ai Risk Ecosystem provides innovative insurance data solutions to the insurance market and is designed to meet today’s business goals with a user-friendly, future-proof platform that can readily adapt to your business needs.

A modern SaaS platform with native artificial intelligence and role-based, smart automation. Klear.ai brings a full life-cycle approach to claims management, with robust Business Intelligence ( BI ), AI-based predictive analytics supported with integrated automation, and “smart” auditing technology.

Claimant Fraud

Klear.ai Claimant Fraud Detection System has been modelled around 45 red flags observed in actual fraud claims from a large database. The system proactively matches such behaviors with those on the claim file. If found to be matching beyond a threshold level, the claims are flagged for investigation.

The models have been designed by domain experts, validated, and perfected over time in live production environments of Self-Insureds and Third-Party Administrators.

Provider Fraud

At the core, the Klear.ai has independent algorithms running to flag cases of Duplicate Bills, Overbilling, Accelerated Billing, Split Billing, ICD & CPT Anomalies, Physician Specialty & CPT mismatches, Rate of Denied Invoices, LEIE (List of Excluded Individuals and Entities) providers and a few others.

The flagged transactions are rolled up at a Provider Level (Physician or Entity) to display a unified 3-Digit risk rating score. The intelligent score measures the risk posed by a provider in terms of Frequency, Severity and Breadth – covering the magnitude and the methodology of fraud, abuse and wastage being perpetuated by a provider.

Why Klear.ai

Klear.ai's innovative and highly effective approaches to the most pressing issues you face as Insurance providers and Risk Managers. Specifically, the Data Scientist, Data Analysts and Architects have many years of direct industry experience which translates to transparent and focused solutions for Insurance Carriers, Risk pools, JPAs and Self-Insurers.

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