New AI-powered Capabilities Support Major Case and Individual Investigations
Shift Technology, a provider of AI-powered decision optimization solutions for the global insurance industry, announced the availability of case management for claims fraud detection. Delivered as a fully-integrated add-on module for the company’s award-winning Shift Claims Fraud Detection, Case Management provides an end-to-end workflow designed to meet the specific needs of SIUs as they investigate suspicious claims from referral to closure.
According to the Coalition Against Insurance Fraud, insurers are subject to more than $300 billion in fraudulent claims per year. While effective detection is a crucial step in mitigating fraud, insurers also need an efficient method for managing, reporting and understanding the impact of the investigated claim on claims costs. Without an integrated approach, SIU teams face time-consuming investigations where they are forced to balance multiple systems and manual document collection, which may also expose them to regulatory and compliance issues. Shift’s integrated case management module addresses these concerns by providing a self-contained, AI-powered environment with the functionality and tools required to take an investigation from initiation to completion in the most effective, efficient and complete manner possible.
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“When considering how to best combat insurance fraud it is important to remember that finding the suspicious claim is just the beginning of the process for claims professionals and investigators,” commented Nicolas Michellod, digital proposition leader, Celent. “The resulting investigation will determine if the claim is legitimate or not. As such, it is important for SIU teams to have access to tools that can manage and guide their efforts to help them reach the best outcome possible.”
Shift spearheaded the use of artificial intelligence (AI) to help insurance professionals make the best decisions possible throughout the claims and underwriting lifecycle. Now, Shift is advancing the state of the art in case management by applying AI to this important business function. Shift’s case management solution offers key capabilities including:
Unified and Integrated Fraud Investigation Management: The solution supports end-to-end workflow from referral generation to impact management across all lines of business and referral sources. As such, the case management module’s UI, workflows and reporting are seamlessly integrated with the fraud detection system already in use which allows for direct access to all of the internal and external data sources relevant to investigating the case. This enables efficient case investigations by eliminating the need for investigators to switch between disparate, siloed environments — which often occurs when using stand-alone case management tools — as they move from the detection to investigation phase.
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Designed for Individual and Major Case Investigations: Recognizing that all cases are unique, Shift’s case management module includes capabilities designed to support the most complex multi-claim provider and network investigations as well as opportunistic and/or individual fraud. These include tailored workflows, network visualization and exploration, and advanced documentation for understanding case impact on claims losses.
Intelligent Investigation: Shift’s AI capabilities support and accelerate case investigation with intuitive tools that cover automated assignment management, identification of team tasks, and structured collection and storage of evidence, among others. Using Generative AI, investigators are also able to search the entire case file, across both structured and unstructured data, to efficiently summarize key documentation and reduce investigation time.
Strategic Insights: The case management module features continuous tracking and reporting of fraud trends and investigation performance, such as dollar impact, time to closure, and task and team/investigator performance analysis. These insights are invaluable to ongoing SIU team training, organization and efficiency.
Compliance and Security: To ensure regulatory compliance, the solution includes detailed audit trail as well as advanced access management and permission features. These can be tailored at a case level and are delivered in a highly secure, confidential environment. Role-based permission and management ensures that individual users are granted secure and role-appropriate access to their respective case data and workflows.
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“When a suspicious claim is identified, it is up to the SIU to investigate and determine if it is truly fraudulent or not,” explained Eric Sibony, chief scientist and chief product officer, Shift Technology. “With Case Management for Shift Claims Fraud Detection we are giving investigators the full set of AI-powered tools they need, fully integrated into an environment which they already know, to do this important part of the job as quickly, thoroughly, and fairly as possible.”
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