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Finance/Insurance

LARGE GLOBAL INSURANCE COMPANY

Project Synopsis

Fraud Detection System

Analyse claims submitted by various healthcare providers and facilities on behalf of insurer to detect inaccurate submission or fraudulent activities. The claims database contained redundant occurrences of records for the providers, facilities and insurer in multiple formats. Due to the inconsistency of data formats within the claims database and across other source systems, it was not possible to apply most of the fraud detection related business rules.

Solution

Denologix was assigned to implement this project in February 2011. Denologix proposed to create repositories for providers, facilities and the insurer that will contain clean and non-redundant data based on operational data from all source systems including the claims database. The steps undertaken to implement this project successfully are as follows:

  • Worked with the client to establish an information governance committee consisting of senior management and Denologix program manager
  • Assisted the client with the implementation of the information governance framework to define the attributes and associated business rules
  • Installed and configure dxHUB within the client environment
  • Configured operational source systems that supply the data to be cleansed
  • Configured web service to retrieve third party data pertaining to the providers and the facilities
  • Configured business rules to clean, standardize, enrich and match insurer data
  • Define metadata for all data attributes within the master data repository
  • Configured data security rules to ensure access by authorized users only
  • Scheduled daily execution of the dxHUB job to create the master data repository for the providers, facilities and the insurers
  • Implemented fraud detection business rules and produced a dashboard and analytical reports to publish the overall claims statistics along with suspicious activities
  • During the first year after the implementation, the fraud investigation unit identified 17% of all submitted claims to be suspicious which warranted further investigation

Technology

  • dxHUB
  • Oracle RDBMS
  • Web service connectors
  • SAP connectors
  • SQLServer and DB2 database connectors
  • Fixed and delimited file based connectors
  • dxDASHBOARD
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what clients are saying

  • Canadian Bank - Data Analytics Regulatory Project

    Their ability to understand customer needs is quite special. Denologix was very good at listening to us and coming up with solutions, which they were able to sell to our own internal clients easily.

    Director, Major Canadian Bank

  • Insurance Company SAS Implementation and Migration

    Their team is very honest. Their leaders are very transparent and open. Partnership like this, you don’t find anywhere. I met very few vendors that I could say that I trusted. This vendor is amazing. I am happy I chose Denologix and would do it again.

    Sr. Manager, Global Insurance Provider

  • Major Bank Regulatory Data Analytics Project

    Terrific. Denologix has a fantastic reputation with our business in terms of being flexible. They are very rapid in acquiring new capabilities. They have established strong customer relationships and relationships with internal SAS departments. I have nothing but good things to say about them.

    Vice President, Alliances Business Development

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