Insurance Fraud Detection Solutions: 2022 Health Insurance Edition

A claims fraud-detection system helps insurance providers identify fraudulent claims, at both the individual and organizational levels. It is typically used by claims teams. There are a variety of business benefits that can be achieved from claims fraud-detection solutions, but two of the primary goals are:

• Improving the carrier’s loss ratio by identifying illegitimate claims.
• Enhancing the overall customer experience by giving providers the confidence to quickly indemnify claims that are deemed valid.

This report provides an overview of fraud-detection solutions for health insurance providers. The report profiles 5 claims fraud-detection solutions providing an overview of their functionality, customer base, technology, SaaS capabilities, implementation, pricing, and support. The following vendors and solutions are included in this report:

• FraudKeeper: FraudKeeper
• Munich Re HealthTech: SHIELD- Software for Health Insurance Eligibility Detection
• Perceptiviti: Sherlock Platform
• SAS: SAS® Detection and Investigation for Health Care
• Shift Technology: Shift Claims Fraud Detection

While this list is not by any means exhaustive, Celent believes it provides a valuable sampling of vendors.

This report aims to help health insurers define their claims fraud-detection solution requirements if they are looking to select a partner. It can be used as the first step toward creating a short list of vendors for evaluation. Insurers continue to have a broad spectrum of systems and vendors to consider when looking for a solution to fit their needs. Insurers can leverage their access to the authors through analyst access calls to learn more about the vendors.