Member Validation Using AI/ML for Largest Major Health Solutions Provider

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Case Study: AI/ML Solutions

Member Validation Using AI/ML for Largest Major Health Solutions Provider

SUMMARY

A large health solutions provider was having difficulty meeting contractual obligations to insurance providers, causing financial losses due to errors when manually validating benefits against provider's benefit plans. Spearhead Technology introduced AI/ML solutions to automatically, and continuously, validate plans and allowed the client to minimize contractual-driven financial losses.

Challenges

  • Client acts as a benefits manager for several large insurance providers in which Client needs to continuously validate beneficiaries (members) against the providers’ benefit plans. The Client’s process to administer the validation process is manual where significant errors are occurring, and the client’s can’t meet its contractual obligations to its insurance providers, incurring financial losses

Solutions Offered

  • The AI/ML solution automatically validates members to plan benefits by predicting and classifying risk levels invalidation workflow using deep neural networks. The solution’s intellectual output covered issues that stemmed from data quality to potentially fraudulent transactions.
  • The AI/ML solution enables the client to effectively manage its insurance providers members to benefit from plans validation by meeting applicable SLAs while significantly minimizing contractual-driven financial losses.