CASE STUDY

Fraud Analytics Uncovers Significant Savings Opportunities for a Leading Healthcare Insurance Provider

May 16, 2019

The client is a leading health insurance service provider based out of the United States. They were looking at leveraging fraud analytics to identify the potential losses from healthcare frauds and errors in claims processing. The client also wanted to implement a systematic, analytics-driven approach that would provide the much-needed insights into false claims.

The Business Challenge

In a rapidly changing business environment tackling fraud has turned out to be a major challenge for healthcare service providers. To tackle insurance frauds, healthcare organizations today are focusing on developing robust solutions that would help them categorize and prioritize suspicious activities. Moreover, the costs incurred due to fraudulent claims processes is much greater than the total cost of quality as it occurs at a downstream point in the sales lifecycle. As such, health insurance service providers are focusing on reducing significant wastage of resources by preventing fraud and abuse in the administration of health insurance claims.

The Business Challenge

In a rapidly changing business environment tackling fraud has turned out to be a major challenge for healthcare service providers. To tackle insurance frauds, healthcare organizations today are focusing on developing robust solutions that would help them categorize and prioritize suspicious activities. Moreover, the costs incurred due to fraudulent claims processes is much greater than the total cost of quality as it occurs at a downstream point in the sales lifecycle. As such, health insurance service providers are focusing on reducing significant wastage of resources by preventing fraud and abuse in the administration of health insurance claims.

Request a free proposal to understand how we can help you in prototyping the complex data sets to gain much-needed insights to create highly-effective fraud analytics models.

The healthcare insurance firm faced several issues due to their inability to detect fraudulent health insurance claims. The client faced several issues due to the following healthcare fraud techniques:

  • Filling claims for medical services which were not actually received
  • Falsifying records of eligibility for obtaining a lower premium rate
  • Using another person’s health insurance coverage to illegally claim insurance benefits

Solutions Offered and Value Delivered

Facing several such challenges the healthcare insurance firm had to deploy new strategies to identify false claims and allocate their resources efficiently. Quantzig’s fraud analytics solutions helped them address this challenge by providing adequate insights into the data obtained from the suspect entity and the other associated entities. The solutions offered also leveraged advanced fraud analytics techniques to analyze claims data in real-time in order to generate warnings of suspected fraud.

The offered fraud analytics solutions also empowered the client to:

Request a free demo to know more about how our fraud analytics solutions can help you detect fraud earlier to mitigate loss and prevent cascading damage. 

  • Leverage fraud analytics to identify and track fraud in real-time
  • Analyze data using interactive dashboards
  • Leverage analytics through cross-application data integration

Why Quantzig?

Quantzig is one of the top companies that are well-known for offering advanced analytics solutions to tackle fraud across industries. With several years of experience in offering advanced fraud analytics solutions, we understand the ‘pain-points’ encountered by healthcare players. We offer a variety of end-to-end advanced analytics solutions that help inculcate the necessary capabilities while offering true business benefits to your organization.

Ready to Harness Game-Changing Insights?

Request a free solution pilot to know how we can help you derive intelligent, actionable insights from complex, unstructured data with minimum effort to drive competitive readiness, market excellence, and success.

Recent Case Studies

Industries

Our advanced analytics expertise spans across industries, sectors, and functions, which enables us to deliver robust, agile solutions to all our clients. These are our core competencies, formed through years of experience.

Insights

Our free resources shed light on our extensive expertise and equip you with information to accelerate decision-making, growth, and innovation.