Pearl Uncovers Additional $3-6 Billion in Dental Insurance Fraud; Offers Artificial Intelligence Solution to a Nearly $18B Pernicious Fraud Trend
Pearl today announced two new breakthrough software products in the application of artificial intelligence and computer vision to dental insurance claims processing. Together, Pearl's new AI solutions represent a massive leap forward for dental insurers, allowing them to review every single dental radiograph with superhuman precision. Pearl's new dental insurance solutions replace existing automation processes that simply cannot catch fraud, waste, and abuse, in part because they rely solely on statistically informed and heuristic processes.
Launching today as GA, the first two Pearl AI software solutions for dental insurance companies are Pearl Claims Approval and Pearl Protect. Across pilots with several national dental insurers, Pearl has uncovered a persistent and pernicious fraud trend. Pearl has identified an additional $3-6 billion worth of dental insurance fraud on top of the $12.5 billion estimated by the National Health Care Anti-Fraud Association. Pearl's findings suggest that of the $250 Billion spent on dental care annually in the US, up to 7% is lost to dental fraud and abuse - representing a two percent increase in total fraud over previous estimates.
Among Pearl's findings:
• One provider used the same toothless panoramic image to get insurance approvals for expensive dentures for almost 40 patients.
• One provider submitted the same patient's full mouth x-rays 18 times for more work and to re-seek insurance approval
• Several providers have been using the same x-rays to get insurance approvals for patients of radically differing ages (fairly flagrant fraud that was going undetected)
"Every week there are new headline reports of dental fraud with individual cases ranging from the tens of thousands to millions of dollars, suggesting that many more cases escape the news cycle and that the extent of dental fraud is significantly under-reported," said Ophir Tanz, CEO and Founder of Pearl. "Our data backs this up. Our dental insurance AI solutions introduce systematic scrutiny of every single claim image and thereby shores up one of the dental industry's most significant vulnerabilities for insurers, for patients and for the vast majority of dental providers who are good actors.
The new Pearl Protect product is designed to flag claims when a 2D image is a duplicate or near duplicate of an existing claim. For example, if a dental insurer receives a claim and supporting proof (imagery, x-rays, intraoral scans) from a dental provider, Pearl Protect will automatically send the imagery to the Pearl API to perform a visual analysis, generate a fingerprint for that claim and check against prior claims to ensure the claim is unique.
Pearl's new Claims Approval product is designed to segment dental insurance claims (strong, moderate, weak) for approval or review based on analysis of supportive scans relative to the claim. For example, if a dental insurer receives a claim and accompanying proof (visual imagery, x-rays, scans), Pearl Claims Approval conducts a visual analysis of imagery morphology and defects, applies a heuristic engine to compare defects against what constitutes a valid claim (per carrier) and then recommends claims routing based on prevalence and consensus of detected defects.
Claims Approval segmentation and automated approvals introduces efficiency that allows insurers to process a high volume of claims more quickly, while simultaneously reducing waste. Automatic approvals for the strongest claims will eliminate the need for multiple submissions of the same claims.
Automatic approvals for the strongest claims also cuts down on the total volume of claims going into the manual review process. Claims Approval routes moderate and weak claims so that insurers provide appropriate levels of human intervention to 100% of claims that truly require additional scrutiny, thereby eliminating fraud and abuse.