Insurtech Sprout.ai today announces the release of its transformational claim settlement solution for health insurers globally, utilising Contextual AI.
With the pandemic driving a 55% increase in average policyholder contact time, health insurers are struggling with complicated systems that are leading institutions to disregard potential fraud.
Up to 20% of claims made by health insurance users are for low value treatments. Some insurers have chosen to simply automate the authorisation of such low value claims without checking them, due to the convoluted classification systems for medication and illness that underpin current processes.
These multiple, highly complex classification systems, such as ICD10, Snomed and MedDRA, include discrete codes for different dosages of the same medication and for each medicine under its various brand names. These complexities lead to claims being lost during processing, creating waste and ultimately facilitating fraud.
Sprout.ai’s solution helps insurers overcome this by putting safety measures in place. Through Contextual AI, Sprout.ai is able to leverage the underlying symptom-based data for each claim based on illness, medication and treatment, including symptoms linked to specific conditions.
Sprout.ai’s web crawlers, able to access over 50 global databases, including the World Health Organisation (WHO) website, can enrich insurers’ data up to 300%. Sprout.ai’s solution allows health insurance companies to immediately diagnose whether a connection can be identified between the treatment and illness specified in a claim.
Sprout.ai’s proprietary algorithms can also process unstructured data associated with each claim, such as medical prescriptions or hospital invoices, even when handwritten or damaged.
Tony Emms, former CCO at Zurich UK and Sprout.ai advisory board member, says: “This solution is potentially transformational for the health insurance industry. Claim handling based on illness and medication coding frameworks create a huge amount of complexity. Medical claims are often the most difficult to handle because of these issues and their high volume, low value nature. By circumventing the coding system, with an entirely justified reasoning behind the triage, Sprout.ai has simplified the process for claims handlers. This solution will succeed because it impacts both leakage detection and efficiency gains simultaneously.”
Sprout.ai CEO, Niels Thone adds: “Even before the pandemic hit, health insurers were struggling to check claims sufficiently. They’ve had to abandon fraud checks in up to a fifth of all claims they receive.
“Sprout.ai’s new diagnostic approach is revolutionary. Insurers will no longer have to rely on automations based on pricing alone but can use the power of Contextual AI to check their data. By removing inefficiency and tackling fraud, we can make the claims system fairer and faster, increasing customer satisfaction. Early adopters are already seeing the benefits and other health global health insurers are now looking towards full implementation of the Sprout.ai product suite.”