Claim Watch - AI is not just a buzzword...

June 18, 2024

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The Claim Watch team uses many resources and tools during their investigative process. At the center of this technological toolkit is Artificial intelligence (AI), which aids in analyzing large volumes of data and identifying unusual patterns and outliers for further investigation.

Dental claim activity generates a significant and wide range of data. While conventional reporting methods offer insights, it is no longer enough to identify fraud and abuse trends throughout the entire dental claim history. Recognizing this limitation, the Claim Watch team uses an AI platform, which conducts peer to peer analysis, predictive modeling, social network analysis, rules monitoring, and more, to better identify instances of fraud.  

Our team recently received an alert from our AI platform, highlighting a potential concern in submitted dental claims. The system identified instances where the plan member's name closely resembled or matched the provider's name. After conducting a deeper review, our team confirmed the AI platform alert and went to work on the case to establish that the plan member and the provider were the same person.

We prepared a list of interview questions, and an analyst called the dental office. The interview uncovered that the dentist had been submitting claims indicating she had performed treatments on herself. When the dentist had realized she had been “caught”, she confessed that her friends had done the treatments. Ironically, she couldn't recall the names of these friends. She stated that she submitted the claims under her own name and unique provider number because her friends were not registered at her clinic.

The dentist informed the analyst that if this activity wasn’t allowed, she would repay the money. It was a quick and straightforward victory for the Claim Watch team, and we were able to retrieve just shy of $7,000!

Our analyst submitted a formal complaint to the Royal College of Dental Surgeons of Ontario (RCDSO).

The RCDSO is one of twenty-six health regulatory colleges in the province of Ontario with the responsibility and the legal authority to protect the rights of patients. The College is responsible for: protecting the public's right to safe, quality oral health care services.  

The provider did send a formal apology, but this doesn’t grant forgiveness for fraud. Fortunately, this dentist won’t have to worry about remembering patient names for submitting future claims.

Well done to the Claim Watch team!

About Claim Watch

Claim Watch provides intelligence led, professionally aggressive fraud management strategies and solutions tailored to our partners. By employing cutting edge technology in data analytics, as well as proven investigational techniques, our team identifies and halts fraud and abuse quickly, thereby minimizing losses.

For further information, do not hesitate to contact us at 1-888-525-7587 or