The ability to gain insights from data sets is directly tied to the rising importance of gaining actionable Investigative Intelligence within financial institutions, and particularly within Fraud Risk Analysis departments. This case study highlights how insurance companies, in this case a health insurance provider, can mitigate their risk by conducting investigative research across previously siloed and un-related data sets.
A top US Health insurance company was concerned about patterns of claims from particular hospitals, doctors, geography and patients but had no consistent source of investigative data to initiate detailed investigations. Suspicions were based on intuition not on facts
The Health Insurance company was able to collect and link all claims into a single Siren environment. This allowed a single repository of documents, databases, emails and all forms of correspondence in a single place. From that a knowledge graph was built and connections and patterns were found across common high risk claims with definitive proof of connections and relationships on fraudulent claims
The Fraud Research function has for the first time solid irrefutable facts on patterns of patients claims which could be rejected from particular doctors and hospitals. Having documentary relationship models and patterns gave the legal backup to hold firm saving the firm millions of dollars on fraudulent claims. This system can be used entirely by Fraud Research professionals without the requirement for frequent IT intervention.
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