Why Insurers Struggle to Control Fraud, Waste, and Abuse
Insurance executives know there’s waste in the system, but identifying it—and fixing it—is an ongoing struggle.
Approvals happen without full visibility. Some decisions follow policy, others don’t. Fraud gets flagged too late, after the money is gone. Are claims being approved consistently? Are fraud patterns slipping through unnoticed? How much money is being lost right now?
The Missing Piece: Structure, Transparency, and Visibility
Fraud, waste, and abuse persist because insurers lack:
- A structured approval system – so every claim follows a trackable, rules-based process.
- Real-time fraud & compliance validation – so risk is assessed before a claim is approved.
- Continuous post-payment auditing – so fraud patterns don’t go unnoticed.
- A way to adjust fraud detection and approval dynamically – so rules evolve as fraud tactics change.
Structured, Trackable Approval System
Ensures every authorization request follows a standard, auditable process. No more approvals based on inconsistent reviews – every decision follows policy rules.
AI-Powered Fraud & Compliance Validation
Evaluates every request in real-time against policy rules, formulary constraints, and patient history.
Post-Payment Fraud Auditing
Continuously scans paid claims to detect hidden fraud patterns, refining risk models over time.
Real-Time Fraud Analytics & Reporting
Provides live fraud monitoring, compliance dashboards, and real-time alerts, so insurers can proactively adapt.
What Happens After Implementation?
What Changes?
With our solution, insurers gain clarity, structure, and confidence in their claims process.
- A structured, trackable approval process—so every claim follows policy rules.
- AI-driven fraud scoring before approvals—so bad claims never get through.
- Continuous fraud auditing—so emerging fraud patterns are detected in real time.
- Live analytics & compliance monitoring—so insurers always stay ahead of risk.
Instead of uncertainty, insurers get control. Instead of hidden fraud, they get visibility. Instead of playing catch-up, they get proactive fraud prevention.
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