(Image credit: Valelopardo.)
Cigna (Bloomfield, Conn.), a global health insurance and services company, has licensed Shift Technology’s Force fraud detection solution to support its International Operations Unit, which designs, implements and manages international group health insurance and employee benefits programs for globally mobile employees.
“Fraud is not a ‘victimless’ crime, and it’s not only insurers that could be hurt by it,” comments David Curlett, Head of Fraud Waste and Abuse, Cigna. “Everyone, especially policyholders, lose when fraud goes undetected and non-meritorious claims are paid,” explained David Curlett, Head of Fraud Waste and Abuse, Cigna. “We’ve long taken a holistic approach to fighting fraud and continuously look for innovative ways to improve our capabilities in fraud detection. Identifying suspicious claims earlier and better understanding why they were flagged, means we can act even quicker to investigate and reach the best possible resolution for our customers and clients.”
Cigna reports that it seeks to detect fraud from various sources through multi-layered Fraud, Waste and Abuse (FWA) protection systems. The company has a comprehensive risk management program combining a set of preventive and detective fraud checks monitors and protects against internal fraud. “The solutions offered by Shift fit firmly within this paradigm,” a Cigna statement says.
Shift characterizes Force’s AI models as able to tighten the level of security by identifying potential fraud perpetrated by individuals. They further enhance security by making correlations within the insurer’s full data set, allowing the technology to build and connect the “social networks” of related entities to detect and extract only the most highly suspicious “sub-networks” within the larger networks, the vendor says.
Detecting Fraud Before the Claim is Paid
“Applying Force’s AI-native technology to the health insurance claims process significantly increases the discovery of fraud, waste and abuse cases before the claim is paid,” comments Jérémy Jawish, CEO and co‑founder, Shift Technology. “This is incredibly important: it gives Cigna the power to fight fraud proactively rather than after the fact, when payments for illegitimate claims may have already been made.”