Detect and prevent fraud in your health insurance business

Automate claims, reduce costs, make better decisions and improve turnaround time

Fraud: One of the most expensive challenges insurers face

Detecting and preventing fraud is a challenge for health insurers globally. Costing between 5% and 10% of an insurance company annual revenue, fraud has continued to grow, fuelled by rise of telehealth and telemedicine.

According to analysts, only a small percentage of medical claims are being properly examined for fraud, and those are mainly claims related to life and mortality benefits. On the other hand, medical claims are typically large volume and high frequency, which means they would need teams of experts to investigate them properly, resulting in higher costs and increased turnaround time. This is the area where SHIELD can add value by automating the medical adjudication of claims, and improving cost containment through detection of potential fraudulent cases.

Addressing your needs as an insurer

To optimize their health claims outcomes, insurers today need a new and modern approach that will automate their claims processing and lead to better decision making, faster claims responses and settlements, and more cost saving. With SHIELD you can:

  • Improve your cost containment activities, leading to reduced claim costs and loss ratios
  • Manage denials efficiently and transparently
  • Improve turnaround times
  • Increase customer satisfaction
  • Strengthen compliance

The business challenges you face

As an insurer, you face challenges related to claims processing from the day a claim is received until the final stage of settlement. The most common challenges include: 

  • Limited capacity to investigate every suspicious claim
  • Tight SLAs with medical providers for denial management
  • Legacy system limitations
  • Lack of meaningful, structured data
  • Data protection laws that prevent use of data
  • Constantly evolving fraud patterns

Put a SHIELD in place to prevent fraud

SHIELD is a system that detects and prevents potential fraud, waste and abuse in medical claims before they are paid. It combines deterministic and machine learning models that automate the medical adjudication of the claim and justify denials.

SHIELD goes above and beyond what others provide

  • Unlike other deterministic rule engines, SHIELD comes with standard rule sets for specific geographies but also gives insurers the flexibility to modify rules or add their own.
  • Unlike other fraud analytics solutions, SHIELD not only detects potential fraud but can also approve or reject a claim, based on deterministic rules and machine learning models. 
  • SHIELD uses a Supervised and an Unsupervised Machine Learning model, to automate decisions.

SHIELD your company from fraud in these areas

  • Outpatient
  • In-Patient
  • Dental
  • Pharmacy
  • Pre-Authorisations

Who would benefit from SHIELD?

Who would benefit from SMAART?

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How you benefit from SHIELD?

SHIELD optimizes and automates medical claims processing and lets you respond more quickly to claimants and resolve legitimate claims faster, leading to greater customer satisfaction. More specifically, SHIELD provides:

  • Increased capacity to investigate and detect anomalies and inconsistencies
  • Enhanced SLA compliance
  • Improved turnaround time and customer experience
  • Easy integration with existing processes and systems
  • Lower claim costs
  • Enhanced accuracy and efficiency in claims processing and payments

Key features & capabilities to manage your business

SHIELD comes equipped with an extensive feature list to help you successfully manage your business:
Deterministic medical rule engine
Deterministic outlier rule engine
Supervised machine learning model
Unsupervised machine learning model
Additional general features

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Expertise and technology behind the solution

SHIELD uses a deterministic rule engine that leverages rules developed by medical experts.

SHIELD AI power is fuelled by an HDBSCAN density-based clustering algorithm and a LightGBM boosted tree model.

Deployment and licensing options that work best for your business

Deployment and licensing options that work best for your business

Get a custom demo using your own data

Get a custom demo using your own data

See meaningful results, instantly. Book a demo with a SHIELD expert