Insurance Fraud Detection: Leverage Data to Accurately Identify Fraudulent Claims
Customer Company Size
Large Corporate
Region
- Europe
Country
- France
Product
- Dataiku Data Science Studio (DSS)
Tech Stack
- Python
- Scikit-Learn
- R
Implementation Scale
- Enterprise-wide Deployment
Impact Metrics
- Cost Savings
- Productivity Improvements
Technology Category
- Analytics & Modeling - Machine Learning
- Analytics & Modeling - Predictive Analytics
Applicable Industries
- Finance & Insurance
Applicable Functions
- Business Operation
Use Cases
- Fraud Detection
Services
- Data Science Services
About The Customer
Santéclair is a subsidiary of several supplementary health insurance companies, including Allianz, Maaf-MMA, Ipeca Prévoyance, and Mutuelle Générale de la Police. They support the health care of more than 10 million beneficiaries, helping to cover optical, dental, and aural expenses as well as dietetic and orthopedic services. For more than 13 years, Santéclair has proven their expertise in risk management, benefiting more than 50 health insurance companies. They are based in Europe and operate in the financial services industry.
The Challenge
Insurance organizations are constantly exposed to fraud risks, including false claims, false billings, unnecessary procedures, staged incidents, and withholding of information. Santéclair, a subsidiary of several supplementary health insurance companies, was struggling with fraudulent reimbursements from both opticians and patients. They lacked a system that could effectively analyze the right data and adapt to increasingly sophisticated fraudsters. Instead, they relied on “if-then-else” business rules to identify likely fraud cases, which resulted in the manual audit team spending their time on too many low-risk cases. With the increase of reimbursement volume (more than 1.5M a year), they needed to improve their efficiency and productivity.
The Solution
Santéclair found a solution in Dataiku Data Science Studio (DSS) via a POC led by the IMT TeraLab platform. Eulidia, a data consulting agency, produced an algorithm using Dataiku to help the manual audit team identify more fraud by feeding them cases with a high likelihood of actually being fraudulent. The solution involved outsmarting fraudsters with advanced machine learning algorithms that continually update and automatically learn or retrain using the latest data so that any new fraud patterns are immediately identified and audited. Dataiku handles the entire workflow, from raw data to exposing the predictive model to the operational applications. The solution also involved automatically combining hundreds of variables from different datasets, including patient/prescriber history, interaction graphs, prescription characteristics, and other contextual data.
Operational Impact
Quantitative Benefit
Case Study missing?
Start adding your own!
Register with your work email and create a new case study profile for your business.
Related Case Studies.
Case Study
Real-time In-vehicle Monitoring
The telematic solution provides this vital premium-adjusting information. The solution also helps detect and deter vehicle or trailer theft – as soon as a theft occurs, monitoring personnel can alert the appropriate authorities, providing an exact location.“With more and more insurance companies and major fleet operators interested in monitoring driver behaviour on the grounds of road safety, efficient logistics and costs, the market for this type of device and associated e-business services is growing rapidly within Italy and the rest of Europe,” says Franco.“The insurance companies are especially interested in the pay-per-use and pay-as-you-drive applications while other organisations employ the technology for road user charging.”“One million vehicles in Italy currently carry such devices and forecasts indicate that the European market will increase tenfold by 2014.However, for our technology to work effectively, we needed a highly reliable wireless data network to carry the information between the vehicles and monitoring stations.”
Case Study
Safety First with Folksam
The competitiveness of the car insurance market is driving UBI growth as a means for insurance companies to differentiate their customer propositions as well as improving operational efficiency. An insurance model - usage-based insurance ("UBI") - offers possibilities for insurers to do more efficient market segmentation and accurate risk assessment and pricing. Insurers require an IoT solution for the purpose of data collection and performance analysis
Case Study
Smooth Transition to Energy Savings
The building was equipped with four end-of-life Trane water cooled chillers, located in the basement. Johnson Controls installed four York water cooled centrifugal chillers with unit mounted variable speed drives and a total installed cooling capacity of 6,8 MW. Each chiller has a capacity of 1,6 MW (variable to 1.9MW depending upon condenser water temperatures). Johnson Controls needed to design the equipment in such way that it would fit the dimensional constraints of the existing plant area and plant access route but also the specific performance requirements of the client. Morgan Stanley required the chiller plant to match the building load profile, turn down to match the low load requirement when needed and provide an improvement in the Energy Efficiency Ratio across the entire operating range. Other requirements were a reduction in the chiller noise level to improve the working environment in the plant room and a wide operating envelope coupled with intelligent controls to allow possible variation in both flow rate and temperature. The latter was needed to leverage increased capacity from a reduced number of machines during the different installation phases and allow future enhancement to a variable primary flow system.
Case Study
Automated Pallet Labeling Solution for SPR Packaging
SPR Packaging, an American supplier of packaging solutions, was in search of an automated pallet labeling solution that could meet their immediate and future needs. They aimed to equip their lines with automatic printer applicators, but also required a solution that could interface with their accounting software. The challenge was to find a system that could read a 2D code on pallets at the stretch wrapper, track the pallet, and flag any pallets with unread barcodes for inspection. The pallets could be single or double stacked, and the system needed to be able to differentiate between the two. SPR Packaging sought a system integrator with extensive experience in advanced printing and tracking solutions to provide a complete traceability system.
Case Study
Transforming insurance pricing while improving driver safety
The Internet of Things (IoT) is revolutionizing the car insurance industry on a scale not seen since the introduction of the car itself. For decades, premiums have been calculated using proxy-based risk assessment models and historical data. Today, a growing number of innovative companies such as Quebec-based Industrielle Alliance are moving to usage-based insurance (UBI) models, driven by the advancement of telematics technologies and smart tracking devices.
Case Study
MasterCard Improves Customer Experience Through Self-Service Data Prep
Derek Madison, Leader of Business Financial Support at MasterCard, oversees the validation of transactions and cash between two systems, whether they’re MasterCard owned or not. He was charged with identifying new ways to increase efficiency and improve MasterCard processes. At the outset, the 13-person team had to manually reconcile system interfaces using reports that resided on the company’s mainframe. Their first order of business each day was to print 20-30 individual, multi-page reports. Using a ruler to keep their place within each report, they would then hand-key the relevant data, line by line, into Excel for validation. “We’re talking about a task that took 40-80 hours each week,” recalls Madison, “As a growing company with rapidly expanding product offerings, we had to find a better way to prepare this data for analysis.”
