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Fraud Alerts and Case Management

Have a unified view & full control of all potential fraud alerts in the claims system enabling faster and seamless fraud case management for SIU teams on appropriate claims.

Complete fraud detection & fraud case management solution to help investigation & special investigation team unit with system proactively alerts for any potential frauds based on configurable risk scoring & dynamic fraud case management framework.

Overview of Claim Fraud Investigation Application

The claims process is prone to potential frauds where a claimant may try to trick the system to get the benefits or advantages which they are not entitled to get.

Each year insurance companies lose considerable money to such claims. To minimize the loss from such frauds, many insurance companies today have a specialized fraud system to check for potential frauds. However, in doing so, they have created data silos where the adjusters have to log in to multiple systems to settle the claims.

Claims Fraud Detection & Case Management is one of the many applications offered as part of Appcino's Insurance Claims Operation Suite. Each of the provided applications can be deployed independently or in combination with other applications as per the requirements & use cases. This application follows standard insurance practices and is easy to integrate with any Appian application OR external existing claims systems.

Targeted Market Challenges

  • Missing view to see the complex network of relationships - With multiple entities/ objects associated with each claim such as third-parties, SIU cases, contacts, address, past claims. It's getting difficult to see how each of the given entities has been involved in prior reported claims, therefore, having no visibility, which could have been otherwise very helpful in entire fraud investigation case management.
  • No or limited collaboration capabilities - No easy way to document/ annotate any specific entity such as a vehicle, contact, address, phone, etc. which investigation team would like to add to consider or keep in mind if the same entity is involved in future reported claims.
  • Lack of unified claims view - Adjusters have to access multiple disconnected systems to look for claim information resulting in many systems switches, therefore, increasing the settlement time and inaccurate settlement leading to revenue loss for Insurance providers.
  • Every claim type (motor, property, marine, etc.) - has its fraud investigation workflow, with required approval & deadline.
  • Lack of Agility - Many times, the insurers are required to make changes to the claims process based on the regulatory requirements or an outcome of the internal assessment to improve the process.

Key Features

  • Fraud Alerts
    • Dynamic fraud alerts based on the threshold score
    • Configure fraud alerts checklists
    • Claims review and SIU case initiation
    • Custom fraud detection rules with the capability to extend and connect with the AI/ML system
  • UI/UX Enhancements
    • Unified claims view
    • Accident Scene Visualisation on Appian
    • Real-time collaboration and any connected object or event
    • Dedicated Alerts and SIU Cases record
    • Dynamic SIU Fraud Case Management
    • A complete audit of all changes manually or through the automated rule
    • Notes dashboard with all the notes/ comments added by multiple stakeholders
  • Integration with Existing Fraud Systems
    • Get the alerts and notification from your existing fraud systems
    • Automated a custom checklist to look for potential frauds
    • Configure a rule to execute in the fraud systems through Appian

Appcino's Fraud Case Management Impacts

  • Reduced Cost & Time - Have one unified solution to track & work on entire fraud case management - reducing cost & efforts to work on fraud cases.
  • Market Competitiveness - Integrate with any of your existing fraud systems, run alerts based on fraud score on them - giving you a competitive advantage over others!
  • Enhanced User Experience - Dedicated, dense & rich record dashboard for each alert & SIU cases with each alert linked to the corresponding claim and are available on claim record to view to see the possible chances of a given claim being a fraud for a claim adjuster.

Appcino's Connected Claims Insurance Suite

Appcino's Connected Claims Operation Suite of apps offers a complete claims management solution built on Appian. The multiple applications part of this suite includes FNoL intake, adjudication & settlement (multiple LoBs), fraud case management (integration with existing specialized fraud systems), field inspection management, subrogation, litigation case management, and claim finances management (reserves, payment, recoveries). It also comes with multi-channel customer service and process mining apps helping insurers to monitor and improve their claims processes continuously.