Wipro to help detect fraud in US health insurance claims

Software services provider Wipro has said that it is partnering with big data analytics firm Opera Solutions to launch an end-to-end solution to address the issue of fraud, waste, and abuse in healthcare insurance claims in the US.

The solution will combine US-headquartered Opera Solutions’ AI- and machine learning-based fraud, waste and abuse (FWA) detection engine with Wipro’s full-service claim processing capabilities in claims review. 

This includes the forensic examination of questionable claims, audits, adjustments, negotiations, recovery follow-up and payment posting, the companies said in a joint statement.

“Opera Solutions’ powerful entity-based AI-powered approach, when combined with Wipro’s deep claims management expertise, will give us an edge in the market and enable us to create tremendous value for health insurers,” said Nagendra Bandaru, senior vice-president at Wipro Ltd.

Opera Solutions said that its FWA detection engine leverages proprietary entity risk-scoring algorithms that are better than traditional rules-based methods.

While existing approaches primarily search for irregularities on a claim-by-claim basis, Opera Solutions’ detection engine claims to identify anomalous treatment patterns for every healthcare entity - all healthcare providers and physicians across major medical specialties.

"This approach will substantially improve the identification rate of high-risk claims and reduce the number of false positives, or flagged claims that are in fact, legitimate," said Arnab Gupta, chief executive officer and founder of Opera Solutions.

In addition, Wipro claimed that auditors can begin their work with a far more accurately prioritised list of claims to review, along with a detailed background and reason codes for flagged claims, thereby enhancing their efficiency and reducing the turnaround time for claims reviews.

"It reduces the admission of non-allowable claims, as well as customer dissatisfaction arising out of the hold-up of legitimate claims that were flagged, erroneously. This will help healthcare organisations focus on delivering high-quality care in the most efficient manner possible," the company said.