V3Qtor AG/Healthcare/Insurance cost optimisation
Intelligent Claims Engine
Automated claim validation, real-time eligibility checks, fraud-pattern detection and provider-network optimisation on the same pass.
Same daypayment for clean claims
- Practice
- Operations Intelligence
- Sector
- Healthcare, insurance cost optimisation
- Systems involved
- Master Data Management Layer for provider and member master data; ShieldOS for the audit trail
- Why it matters
- Fraud losses estimated in the tens of billions a year1.
What it changes in the P&L
Administrative cost and fraud leakage. Clean claims paid in a day, dirty claims stopped before payment.
How the first weeks go
- Take the event logs you already haveERP, MES or the claims system write a timestamp on every step. We read them, nothing new is installed on the floor.
- Put a number on every queueProcess discovery shows where the work waits and what each hour of waiting costs. The bottleneck is usually not where people think.
- Change one thing and measure itWhat-if scenarios first, then one change in the real process, measured against the baseline. The second change starts when the first number is in.
In an engagement
A health insurer with 1.2 million members moved validation, eligibility and fraud scoring to intake. Clean claims are paid the same day2.
What stays
Intelligent Claims Engine stays in the ward’s rhythm once it runs. The weekly review reads from it and its evidence files into the audit trail. Hand-over comes when the number has held for a quarter.
Talk to us about Intelligent Claims Engine.
Tell us where it would run and what it would have to change. We will come back with what we would look at first, what the first quarter produces, and what it would take.
Notes and sources
- 1National Health Care Anti-Fraud Association, testimony to the U.S. Senate HSGAC subcommittee, October 2011: financial losses from health care fraud estimated in the tens of billions of dollars a year. Source
- 2Illustrative. Anonymised engagement scenarios; figures indicate modeled or targeted impact and are not audited outcomes.