With Covid-19 driving 55% increase in average policyholder contact time, health insurers are at risk of missing fraudulent claims
Insurtech firm Sprout.ai has launched a claim settlement solution for health insurers globally using its Contextual AI technology.
The service puts in safety measures that check health insurance claims, up to 20% of which are for low value treatments. With some insurers choosing to automate the authorisation of claims with low value, they are in danger of missing claims that may be fraudulent, said Sprout.ai.
Current processes rely on complex classification systems, such as ICD10, Snomed and MedDRA which include discrete codes for each medic and their varying brand names, and this can lead to claims being lost during processing, the technology provider added.
Through is Contextual AI solution, Sprout.ai said it is able to leverage the underlying symptom-based data for each claim based on illness, medication and treatment, including symptoms linked to specific conditions.
The firm's web crawlers, able to access over 50 global databases, including the World Health Organisation (WHO) website, allows health insurance companies to instantly diagnose whether a connection can be identified between the treatment and illness specified in a claim, it said.
It uses algorithms to process unstructured data associated with each claim, such as medical prescriptions or hospital invoices, including those that are handwritten or damaged, it said.
With reports suggesting that the Covid-19 pandemic is driving a 55% increase in average policyholder contact time, Sprout.ai suggested that its processes can help insurers struggling with complex processes and help them avoid fraudulent claims.
Tony Emms, former CCO at Zurich UK and Sprout.ai advisory board member, said: "This solution is potentially transformational for the health insurance industry. Claim handling based on illness and medication coding frameworks create a huge amount of complexity. Medical claims are often the most difficult to handle because of these issues and their high volume, low value nature. By circumventing the coding system, with an entirely justified reasoning behind the triage, Sprout.ai has simplified the process for claims handlers. This solution will succeed because it impacts both leakage detection and efficiency gains simultaneously."
Sprout.ai CEO, Niels Thone added: "Even before the pandemic hit, health insurers were struggling to check claims sufficiently. They've had to abandon fraud checks in up to a fifth of all claims they receive.
"Sprout.ai's new diagnostic approach is revolutionary. Insurers will no longer have to rely on automations based on pricing alone but can use the power of Contextual AI to check their data. By removing inefficiency and tackling fraud, we can make the claims system fairer and faster, increasing customer satisfaction. Early adopters are already seeing the benefits and other health global health insurers are now looking towards full implementation of the Sprout.ai product suite."
Formerly known as BlockClaim, Sprout.ai rebranded in June after receiving $2.5m seed funding.
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