AI for Provider Fraud & compliance for Insurance & Healthcare Industry
summary
Aquila is a deployed provider-fraud system inside a NASDAQ-listed carrier that turns millions of billing lines plus external feeds (medical board, licensing, locations) into a provider dashboard and prioritized caseload. It detects kickbacks and suspicious connections via link analysis, flags unlicensed services, finds “treatment not rendered” by impossible cumulative appointment times, spots unbundling and holiday/weekend billing, and compiles prosecutable evidence in days rather than months — producing a first-year impact of $14.3M saved.
AI-written summary · about
chapters (8)
- 0:00Introduction
- 2:38What is Workers Compensation Insurance
- 10:13Traditional Fraud Tools
- 12:52Provider Fraud Example
- 18:13Traditional Tools
- 19:29Data Analytics
- 26:18Use Cases
- 32:18Conclusion
related talks
18mAI That Pays: Lessons from Revenue Cycle
31mAI For Good: Fighting Health Insurance with AI
16mGenAI in Healthcare Claims: Processing and Detecting Fraud
16mAI-Driven Claims Adjudication: Healthcare Efficiency & Fraud Prevention
25mAI for healthcare: Scaling Access and Quality of Care for Everyone
48mAI for Healthcare
18mU.S. Healthcare with AI: Cost Transparency and Affordability
08mAI-Powered Fraud Detection in Financial System