Workers' Compensation Fraud Prevention Software

Fraud Detection covering Claimant Fraud and Provider Fraud

Adopt a culture of 'Proactive Claims Management' using Klear.ai suite of products

Improve tactical, operational and strategic decision with Klear.ai predictive power

Tangible benefits - 10 to 15% in efficiency gains; 15- 20% by preventing fraud, abuse & waste; Increased customer satisfaction

Quick deployment and easy integration with your existing claims management systems through a library of APIsIt's easy.

Fraud, Abuse & Waste Prediction

Klear.ai has strong fraud detection capabilities, covering claimant as well as provider fraud

- Identify suspicious claimant fraud claims early in the claims lifecycle

- Identify suspicious provider bills with great accuracy with over 13 use cases

- Automatically route suspicious claims & transactions to designated SIU personnel

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High Accuracy in Flagging Suspicious Claims

Our proprietary algorithms recognize the peculiarities and complexities of managing the business. The models have been designed by domain experts, validated and perfected over time in live production environments of Self Insureds and Third Party Administrators.

The Klear.ai team analyzes the pattern of actual frauds and programs the system to proactively match such behaviors with suspicious patterns within large data sets.

Currently, Klear.ai models to detect a wide range of suspicious transactions - Claimant Fraud, Provider Fraud, Examiner Fraud and Billing Fraud. Highly elusive cartels, which work together to defraud the payer, are identified through a range of Network Analytical Models with a very high accuracy.

Discover Factors Leading to High Fraud Score

In claimant Fraud, the red flags are identified early on and the corresponding factors are highlighted along with model confidence levels, letting the examiner and SIU verify those factors and build their line of investigation.

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Claimant Fraud

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Provider Risk Rating Models

All the flagged provider transactions are routed to Auditors for verification. Once verified, the data is consolidated to build the 'Provider Risk Rating Model' - a 3 Digit Score, which indicates the magnitude and extent of fraud or abuse being perpetuated by a provider.

Klear.ai further ranks the providers on a dashboard to let you focus on the top few.

Provider Fraud

Fraud Insight Dashboard

Dashboard view provides deep insights in Fraud trends, letting you view Fraud as per claimant demographics, Injury Types, Employment / Job classification and more.

Strategizing based on these insights could help you create a effective fraud prevention program.

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Configure Fraud Notifications

Klear.ai let's you configure notifications for every flagged suspicious claim.

You can designate a SIU specialist, to receive notification with all relevant details.

Automated workflow capabilities are an important component of your fraud, abuse & waste prevention programs.

Klear.ai Predictive Suite use highly sophisticated AI and Deep Learning Models to make accurate predictions of critical claims parameters. Models ingest structured as well as unstructured data (like Adjuster's Notes), run them through a proprietary statistical models to give the final inputs.

In line with dynamic nature of insurance business, the solutions are trained to monitor the hit ratio. And use this data to self improvise over a period of time - further entrenching into the core of your claims operation.