A healthcare firm’s journey towards achieving 96% precision in monthly claims reserve forecasts
The managed healthcare company grappled with operational hurdles, particularly in identifying claim overpayments during adjudication, detecting potential provider fraud early in the claim lifecycle, and enhancing the accuracy of monthly claim liability to prevent blocking additional funds for reserves. In collaboration with Infosys, the company adopted a strategic approach by implementing big data and advanced analytics. This involved the creation of data pipelines to manage various data aspects, the development of overpayment identification concepts, including retrospective terminated coverage and claims pre-certification, and the application of feature engineering analytics for reserves and customer experience. These measures aimed to enhance operational efficiencies and address payment integrity and fraud detection challenges effectively.
