INSURANCE

Siren for Finance in Insurance Industry

Fraud Risk Analysis

Empowering effective Fraud Risk Analysis in the Health Insurance industry

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.

THE PROBLEM

Health Insurance Company Elevated Fraud Risk Levels

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 SOLUTION

Siren Fraud Intelligence

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 OUTCOME

Greatly Reduced Fraud Risk

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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