Wipro Limited in partnership with Opera Solutions announced the launch of an end-to-end solution to address the issue of fraud, waste, and abuse in healthcare insurance claims in the United States.
The solution will combine Opera Solutions’ powerful AI and machine learning based Fraud, Waste and Abuse (FWA) detection engine with Wipro’s extensive full-service claim processing capabilities in claims review, which includes the forensic examination of questionable claims, audits, adjustments, negotiations, recovery follow-up and payment posting.
Opera Solutions’ FWA detection engine leverages proprietary entity risk scoring algorithms that significantly outperform traditional rules-based methods. While existing approaches primarily search for irregularities on a claim-by-claim basis, Opera Solutions’ detection engine goes far beyond claims to identify anomalous treatment patterns for every healthcare entity, i.e., all healthcare providers and physicians across major medical specialties. This approach will substantially improve the identification rate of high-risk claims and reduce the number of false positives, or flagged claims that are in fact, legitimate.
Wipro’s claims auditors can thus begin their work with a far more accurately prioritized list of claims to review, along with a detailed background and reason codes for flagged claims, thereby, enhancing their efficiency and reducing claims review turnaround time. It reduces the admission of non-allowable claims, as well as customer dissatisfaction arising out of the holdup of legitimate claims that were flagged, erroneously. This will help healthcare organizations focus on delivering high-quality care in the most efficient manner possible.
“As one of the global leaders in healthcare insurance claims services, we are aware of the many limitations of automated rules-based systems for first-line claims review,” said Nagendra Bandaru, Senior Vice President and Global Head – Business Process Services, Wipro Limited. “Opera Solutions’ powerful entity-based AI-powered approach, when combined with Wipro’s deep claims management expertise, will give us an edge in the market and enable us to create tremendous value for health insurers.”
Arnab Gupta, Chief Executive Officer and Founder of Opera Solutions said, “Our strategic relationship with Wipro is a perfect example of the ways in which advanced pattern-based AI and machine learning can allow talented and highly experienced people to become even more effective at what they do. We look forward to working with Wipro to take this powerful new capability to the market.”