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Workers Compensation Case Study

A large NYSE listed company achieves 10X ROI in Fraud Prevention and Saves Millions in Workers Compensation Fraud

At A Glance

Our client saved 14 million dollars with in a year of using Aquila’s Worker Compensation
Fraud solution.

Highlights

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Saved over 14 million USD within a year in Provider Fraud
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Accurately quantified the impact of provider fraud

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Reduced closure time of cases from months to days

Business Challenges

Our client through its subsidiaries, operates in the commercial property and casualty insurance industry primarily in the United States. It offers workers’ compensation insurance to small businesses in low to medium hazard industries.

Like most Insurance companies, our client too has a special investigation unit (SIU) to detect and prevent workers compensation fraud. For the past 10 years, the SIU used legacy systems to analyze suspicious claims. This included extremely large volumes of data and millions of records related to claim transactions and billing. The existing system involved a lot of manual work and proved to be very time-consuming. With basic data analytics it was difficult to detect the fraudulent transactions and also get a consolidated view of fraud to analyze and close cases faster. The team spent weeks and months trying to gather transactions to support the legal case.

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“Aquila is state-of-the-art solution with comprehensive use cases to detect fraudulent transactions for any SIU. The solution has helped us discover large scale systematic frauds by means of collusion among various bad actors. It is easy to use and extract reports without relying on IT resources. The solution has delivered 10X ROI and paid for itself in the first year of its adoption.”

Sam King

Vice President, SIU, Employers Insurance Group

Solutions

The solution is built using latest technology like AL/ML and has the ability to see through colluding transactions and actors. The system provides suspicious fraud score which helps the SIU team focus their energy to unearth potential fraud scenarios. Aquila provided a fraud analytics solution with multiple modules including Provider Dashboard, Link Analysis and Claim Analytics that would support over 25 use cases of fraud.

The Provider Dashboard lists the top 10 suspicious providers based on several fraud use cases where SIU team could focus on.
The link analysis feature is a visual map of all actors involved in fraud and their relationships. This is created by analysing over millions of transactions.
The solution made it easy for the investigators to look for suspicious patterns and understand large scale systematic collusions which is not possible to detect when you see several transactions individually.
It provided easy navigation and drill down features to make search between modules faster enabling the SIU team to put together supporting evidence in matter of hours and not weeks or months.

Results

The 25+ prebuilt use cases including unlicensed services, excessive billings, unbundling, treatment not rendered, referral kickbacks and others to flag non-compliant transactions made detecting fraud easier.
SIU team can now use link analysis to discover suspicious connections between various actors from medical provider, billing provider, attorney, rendering provider and claimants.
Stay on top of fraud by performing real time data verification and validation with external data sources such as boards including DIR, SOS, DCA and CMS registry
The solution has enabled easy drill downs to get more details about the claims data
Use the data as case evidence by easily exporting them
It saves SIU weeks of work to accurately quantify accurately the impact of suspicious claims and top suspicious providers