Shift Claims Fraud Detection for Life, Protection and Disability

Shift claims fraud detection enables life and disability insurers to accurately make decisions and detect fraud in real time with enhanced data and powerful, insurance-trained AI

L&D Key Features:

Internal and External Data Integration and Analysis

Sophisticated non supervised data cleansing and mapping that consolidates relevant claims and policy data using data quality routines

Daily retrieval of external data and extraction of unstructured data using OCR and NLP

Identify deduplication and reconstruction of family households

Social network construction (graph clustering)

Claims / policyholder and households history comparison

Group history claims comparison for employee and commercial schemes

Insurance trained AI/ML models and sophisticated predictive analytics

Comprehensive library of scenarios covering loss of earnings, sick leave, critical illness, life, death and funeral products

Supports individual (retail), small and large employee schemes (commercial)

Analysis on claims payable, in progress or recently closed

Automatic anomaly detection and natural language processing of text variables.

Continuous-learning AI/ML models designed to uncover complex fraud and increase accuracy of alerts at the prepayment and post-payment level

Network and collusion discovery and analysis

Network link analysis to uncover unknown linkages or relationships among seemingly unrelated claims, providers and members

Interactive network visualisation allowing investigators to explore network nodes interrogate relationships and add notes

Investigator dashboard with detection results, alerts and full context

Prioritised alerts with clear scoring and supporting alert and investigative information

Configurable investigator dashboard detailing key information regarding the alert including the projected value

In depth alerts detail, showing all attributes and characteristics that have led to the alert score, links to external and internal information found to be relevant and recommendations of next investigative steps.

Reporting

Custom data exploration and reporting including dashboards showing alert detection, qualification and conversion rates, team workload, trending and scenario performance. Confgurable filtering and display.

Case management and workflow

Integrated case-management features for task assignment, team management, communication and collaboration

Document and correspondence management for requesting and storing key documentation and instructing internal teams.

Rapid deployment and dedicated team of Shift experts and DS

Options to run scenarios in batch or real time, real time alerts investigators prior to claim settlement allowing payments to be blocked if necessary.

4 months average implementation time frame with rapid time to value and ROI

Continuous scenario performance monitoring with dedicated Shift DS and CSM teams and where needed scenarios are further fitted to client data to further improve detection and recovery success.

Using a SaaS model, the Customer Success Manager, the Shift Data Scientist, and Shift claim fraud detection’s ML algorithms continually update fraud scenarios to stay current with evolving fraud trends and emerging schemes

L&D Benefits:

Reduce investigation time and lower costs

Save teams significant manual inspection effort and fact gathering with the Shift platform data extraction of key facts from unstructured data.

Remove reliance on experience, basic rules, gut feel and rudimentary prioritisation by leveraging pre trained ML scenarios to accurately flag and prioritse cases..

Reduce investigation cycle time as the Shift platform and UI integrates and unites multiple structured and unstructured data sources, delivering full context directly to investigations.

Find more fraud

Stop more leakage and get instant insights across all claims illuminating networks, relationships and collusions.

Find previously undiscovered complex and major cases with Shift Network Detection, as it assimilates collusions and relationship maps in seconds.

Gain the ability to accurately analyse and check all claims at source rather than having to manually triage a long list of potential cases filtered by simple rules potentially missing more sophisticated cases.

Increase growth

Gain competitive advantage through delivering an even better claims service

Elevate processes in order to prepare for increased policy uptake and claims volumes, to leverage global life and health trends

Reduce audit and recovery effort

Accelerate case workflow and recovery and increase team efficiency with Shift Case management to automate consent and recovery tasks

Consolidate documents, records, audits and reports for each case easing collaboration and saving teams effort

Ensure great customer experience

Fast track genuine claims and deliver great service as Shift scenarios alert and block suspicious claims in real time, routing them to the correct investigation team and away from triage.

Prevent leakage and remove cost immediately from the bottom line as Shift scenarios automate checks on every claim alerting investigators before payments are made.