Insurance Claims Processing

‍Challenge

‍An insurance provider had a manual claims processing system taking 5+ days per claim. The process required claims adjusters to review documentation, verify policy details, assess coverage, detect potential fraud, and calculate payouts, creating a significant operational bottleneck and customer dissatisfaction with slow resolution times.

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Solution

An AI claims assessment and fraud detection system using GPT-4 and n8n that:

• Automatically extracted and validated information from claims documents
• Verified policy coverage and benefit eligibility
• Identified potential fraud indicators using pattern recognition
• Calculated appropriate payout amounts based on policy terms
• Fast-tracked straightforward claims for immediate processing
• Flagged complex or suspicious claims for human review

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Implementation

‍The implementation took 9 weeks:

1. Claims document analysis and information extraction model development
2. Policy verification and benefit calculation automation
3. Fraud detection pattern implementation based on historical claims data
4. Workflow creation for different claims complexity levels
5. Integration with payment processing and notification systems

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Results

• Claims processing time reduced from 5+ days to 6 hours on average
• Fraud detection improved by 43% compared to manual review
• 2.0 FTE saved in claims department operations
• 92% of straightforward claims processed without human intervention
• Customer satisfaction with claims process improved by 58%

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Cost Savings

Beyond operational efficiency, the improved fraud detection represented approximately €420,000 in annual savings from prevented fraudulent payouts.

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