Nigeria’s Curacel is Combating Health Insurance Fraud with AI

Nigeria’s Curacel is Combating Health Insurance Fraud with AI

By Nnamdi Odumody

Curacel is a platform that uses Artificial Intelligence to tackle fraud, waste and, abuse (FWA), in healthcare insurance, thus helping health insurers realize massive time and cost savings. Its solution detects fraud and error in customer data, and speeds up the processing for health insurers, and their partner healthcare providers.

Using an intelligent rules engine, Curacel’s Platform helps Health Insurers realize massive time and cost savings

eClaims

When claims data enters the platform, each claim passes through an extensive data validation process powered by eClaims engine, producing risk scoring metrics and pinpointing FWA in each claim. eClaims comprises simple rules like age and gender as well as extensive machine learning algorithms that consider the full treatment histories.

eVerify

Once individual claims are validated and sanitized, eVerify sniffs its way through the entire database looking for behavioural patterns, collusion networks, and inefficiencies such as upcoding. The unsupervised graph based sweeps learn and adapt to new relevant patterns, spotting complicated patterns that are not visible to unaided human eye.

eMeasure

For top level managers, having the right tools to overview and monitor the business is paramount. eMeasure allows you to summarise and quickly produce management-level reports of your data. With eMeasure, you can narrow down on metrics and statistics such as processed claims, most common violations, total riskiness and estimated FWA figures.

EClaims API provides the main integration point for the customer allowing him or her to leverage the capabilities of Curacel using simple REST/JSON calls. It is simple and configured to work with any hardware as the software can handle both real time and bulk load depending on the use case.

As customer claims are submitted in real time, Curacel responds with live alerts which can easily be integrated into existing workflows to ensure you capture inefficiencies before they arise. In order to protect customer data, Curacel can be deployed on premises or VPN in a secured cloud.  All certificates are supplied by the customer who retains full control of user access management and application tokens.

Curacel currently powers health insurance claims processing for some HMOs in Nigeria and Ghana.

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