Fraud is a major concern for the insurance companies. Fraudulent claims are widely increasing, which is calling on the insurers to adopt stringent measures in detecting insurance fraud. With insurance fraud on the rise, health claims fraud has been coming to the forefront, affecting the insurance industry negatively. Tapping potential fraud at the early stage of claims processing is an important step towards effective claims fraud detection and prevention. 

This case study will be discussing in depth the technological aid that is adapted by our client, who is one of the country’s trusted and leading health insurers. With these technological adaptations the client experienced accurate fraud detection, which also allowed them to bring ease to their operations. 

Client Profile at A Glance 

Our client is one of India’s leading as well as trusted health insurers. They are committed to delivering affordable products that can be accessed by all. With their products they aim to support everyone in their journey towards a healthy life. Trusted by millions across the country, our client is committed to fulfilling diverse health insurance needs. 

Key Challenges that Our Client Faced 

With a rapid rise in fraudulent claims, health insurers are at the edge of tackling seasoned fraudsters who are not just contributing to reputation damage but also significant financial loss. Our client faced a similar challenge of detecting fraudulent health claims with a manual workforce, leading to inaccuracy in fraud detection.  

Here are the challenges that our client faced in a nutshell: 

Manual Investigation Process 

One of the significant challenges that our client faced was the manual investigation process. The manual document verification and medical intent of a claim were done manually, which led to inaccuracy in detecting a legitimate and fraudulent claim. 

Reduced TAT 

With the manual fraud detection, there was a significant time lost in collecting, verifying, and stacking up claims data, which was time-consuming. This delayed the claims processing TAT. 

Absence of Data Organization 

Due to the absence of an advanced technological solution, there was no proper data organization. The entire claims investigation relied on pen and paperwork. 

Digital Solutions Integrated by the Client 

iNube’s claims investigation solution played a pivotal role in aiding the client to combat the challenges. The solution lent a digital helping hand to the client, which helped them to streamline the claims investigation process. With the technological adaptations, the client was able to achieve efficiency in processing claims and flagging potential frauds. 

Here are the implementations that our client carried out: 

Centralized Claims Investigation Solution 

A futuristic claims investigation solution was implemented that eliminated manual processes in claims investigation. Every step of the claim’s investigation was digitized under one centralized platform. 

User Management Platform 

With the implementation of a robust user management platform, the client was able to easily manage the accessibility of the different business partners.  

Case Creation  

Cases uploaded in an API format, which were recorded in a sequence and uploaded to the core system of the customer, eliminating fragmented record keeping 

Case Assignment Module 

The case assignment module enabled automating the claims investigation to the respective claims’ investigators, easing out workload. Additionally, bringing organizations into claims investigations 

Claims Investigation App 

A mobile app for claims investigation was integrated that enabled enhanced visibility and accessibility. Eliminated manual work of keeping tabs on the claim’s investigation status 

Reviewing Module 

With this module, the client was able to review the claims investigation data and know about its status. Enabling them to take swift action for potential fraudulent claims and have operational efficiency 

Breakthrough Results the Client Experienced 

Enhanced Visibility 

The client achieved an increase in their partner visibility, allowing transparency in the claim’s investigation operations. 

Enhanced Data Organization 

With the different modules integrated, the client experienced an organized approach towards claims investigation data, especially in claims record keeping. 

Hassle-Free Claims Investigation 

With a unified platform, the client was able to conduct different claims investigation functionalities within a single system. Eliminating multiple system integrations. 

Digitized Claims Investigation 

The client was able to eliminate the manual document verification processes and opt for digitization with our solution.

Bottom-Line Impact Made 

20k+ claims settled in the last six months

58682+ Claims Processed 

1200+ Users Created 

1200+ Claims Investigated 

9700+ Claims Created per Month 

The integration of the centralized claims investigation solution unlocked efficiency in tapping potential frauds. With the integration of the advanced modules, the client was able to process volumes of claims while exercising scrutiny in fraud detection. Additionally, the client also unlocked multiple scalable benefits with the implementation of iNube’s claims investigation solution. 

Overall, the new system created a lasting impact, which the client experienced in processing legitimate claims and flagging fraudulent ones.