
Daisy's Investigative Workflow Supports Insurance Decision-Making

Fighting fraud has become an increasingly demanding battle – especially as insurers are pressured to provide faster and better service. With resources stretched thin, Daisy aims to provide a better investigative and claims management experience.
Daisy’s integrated suite of solutions detects fraud, automates claims processing, and underwrites risk - delivering incremental value and verifiable financial results. With a workflow that streamlines and consolidates internal systems, insurers are better positioned to achieve overall business objectives and deliver on their organizational mission.
This blog post will provide a high-level overview of
Daisy’s end-to-end investigative workflow and explore
how the capabilities are supporting investigative
efforts and providing considerable value.
End-to-End Investigative Workflow
Daisy’s end-to-end investigative experience supports
suspicion identification through to case investigation
and claims processing. Hosted via an agile and dynamic
online portal, the system offers insurers actionable
recommendations that enable impactful
decision-making.
With the centralization of claims data and explainable
recommendations insurers can trust, insurers are
empowered to take on only the highest value tasks – in
turn, realizing significant time and labour
savings.
Insurance Portal Capabilities
The Daisy workflow begins with suspicion
identification. Investigators can access an alerts
dashboard via the online portal. The dashboard
identifies all suspicious claims or entities, which are
presented hierarchically in terms of their Daisy score
and are filtered using a score threshold chosen by each
organization.
Importantly, each alert comes with a link to an alert summary that provides a comprehensive view of each entity to aid investigators and analysts in deciding if an alert should be accepted for investigation or not. The summary also explains why an entity is suspicious via a suspicion summary - building trust in the system capabilities by offering the rationale behind each decision.
Investigators are now able to accept or deny alerts for investigation. When an alert is accepted, investigators are prompted to create a case. Managers can assign new cases to investigators on their team, who can utilize the portal to log details as progress is made in the investigation. Importantly, Daisy’s recommendations can be leveraged to decide the appropriate course of action for the investigation, such as contacting any individuals involved to validate information. Based on the outcome of the actions taken, investigators can opt to close a case at any time.
To get a granular view into the Daisy portal, download
our
latest whitepaper.
Solutions Supported by the Daisy Workflow
Primarily, the Daisy system identifies fraud by
identifying the
Halo Effect
– i.e., outliers – in claims data. With Daisy uncovering
claims and entities recommended for investigation,
insurers can now identify all suspicious behaviour in
their claims data to proactively eliminate fraud before
costly payments are made. The system capabilities also
enable insurers to recoup payments by finding previously
undetected fraud with great speed.
The Daisy workflow also supports claims automation and straight-through processing by making autonomous claim payment and fraud avoidance decisions. The Daisy system is applied to review claims that fall below the threshold for investigation and provide recommendations for auto-pay, auto-deny, investigation for potential fraud, waste, or abuse, accelerated human review, and full manual adjudication. Should organizations choose to forego fully autonomous review, they can select a level of autonomy that best fits their needs and level of comfort – e.g., tiered human review.
Finally, the Daisy system aligns pricing with risk while minimizing fraud, waste, and abuse at the underwriting stage. Daisy applies peer analysis to underwriting data and looks at the historical claims of peers to identify outliers and high-risk individuals. Daisy will provide a risk or underwriting index to create an appropriate premium for the policy – high risk individuals are assigned a higher premium to cover expected future claims.
The system provides explainability for all
recommendations, meaning insurers can feel confident at
every stage as they leverage system
recommendations.
Daisy’s investigative platform offers specific,
actionable recommendations – enabling insurers to make
the most impactful investigative decisions possible to
achieve their overarching business objectives.
With solutions for fraud detection, claims automation,
and underwriting, insurers can eliminate fraud, waste,
and abuse and minimize human touch in claims processing.
In turn, insurers will discover an improved case
management and investigative experience – making a tough
job easier.
