For EIS, excellence in claims processing, risk assessment, administration, and resolution is key to our mission of supporting digitally driven, future-proof innovation for ambitious insurers.
That’s why earning Celent’s recent recognition as a Technology Standout for ClaimGuard, our risk assessment and fraud detection system, means so much to us. This honor — like the Technology Standout honor Celent gave us for ClaimCore earlier this year — reflects our tireless commitment to perfecting the claims process, so it matches customer and carrier needs now and in the future.
ClaimGuard: Confronting Fraud Risk With ML — and Winning
ClaimGuard — half of the intelligent claims automation solution ClaimSmart — can identify fraud risks extremely early in the claims lifecycle. Every time there’s a first notice of loss (FNOL), ClaimGuard uses multi-variable machine learning (ML) algorithms, advanced analytics, and API-based integration to collect relevant data and weigh the claim against critical factors: customer histories, claim frequency, active fraud cases, and more.
The system uses a proprietary fraud scoring model that distills every claim’s risk level to a quantifiable KPI. If ClaimGuard detects patterns indicative of fraud or other anomalies, the score reflects this. The solution routes claims with problematic scores to special investigation units for meticulous examination. (ClaimGuard also provides dashboards for investigators to observe their caseloads and easily share information with fellow experts.)
Meanwhile, routine and low-risk claims get sent ahead for straightforward processing. This saves time and resources for claims teams and customers alike. After implementing ClaimGuard (alongside ClaimSmart), a major international P&C insurer caught five times more fraud, reduced their claims team’s manual burden, and significantly improved the customer experience for claimants.
ClaimCore: Unlocking Efficiency in Every Claims Lifecycle Phase
ClaimCore, which Celent named a Technology Standout in March 2024, gives insurers thorough control of the claims process through every phase, without sacrificing ease of use or efficiency. The solution includes effective out-of-the-box features for FNOL, administration, investigation, payment, subrogation, catastrophe management, and much more. It also allows carriers to customize UI, rules, workflows, and other processes to properly address unique customer and business needs.
Based on FNOL submissions, ClaimCore assigns processing tasks to the most appropriate business users and initiates automated workflows based on preconfigured rules. (For example, a P&C claim submitted at the scene of a multi-vehicle car accident will go straight to an experienced auto claims examiner.) Simple claims processing can be largely entirely automated, while complex or bundled claims get the closer attention they need.
Robust open APIs enable seamless integration with internal data sources and third-party partner systems. This ensures that as the claims process unfolds, examiners have ready access to all relevant claimant data (customer history, policy conditions, and claims details) and can review it with an easy-to-use dashboard layout. They can return to this context view anytime without jumping back and forth between countless screens.
Better Together: How ClaimGuard Complements ClaimCore
Using ClaimGuard together with ClaimCore grants ambitious insurers unprecedented anti-fraud firepower.
For example, if the ClaimGuard scoring system designates a claim as high-risk, workflows set up with ClaimCore ensure the filing is thoroughly vetted based on configurable rules and close examination by special investigators. ClaimCore also integrates easily with third-party fraud detection tools such as photo analysis applications. This ensures that carriers complete due diligence for any remotely suspicious claim.
Add the claims automation capabilities of ClaimPulse (the other half of ClaimSmart) to the picture, and you’ve got a truly comprehensive claims admin package — backed by versatile, cloud-native, and data-fluid EIS technology.
Ready to Revolutionize Your Claims Lifecycle?
EIS claims solutions enable carriers to accelerate and optimize operations while reducing risk and offsetting claims leakage. To learn more, read Celent’s reports or get in touch with an EIS representative today.
