Case Study: Leading U.S. Workers’ Compensation Insurance Company achieves $8M fraud detection and 60X ROI with Cognizant

Leading U.S. Workers’ Compensation Insurance Company - Customer Case Study

Cognizant worked with a leading U.S. workers’ compensation insurer that suspected widespread healthcare claims fraud. The carrier’s rules‑based, invoice‑level review missed historical and contextual patterns in provider behavior, so existing data couldn’t reliably surface fraudulent activity across claims, providers or geographies.

Cognizant developed an unsupervised machine‑learning provider‑benchmarking methodology that analyzes medical bills across plausibility, outcomes and behavior—flagging anomalies like move‑across‑state patterns, denied‑claim histories, atypical opioid prescriptions and suspicious provider relationships. The solution identified $8M in fraudulent claims, delivered a 60× return on the carrier’s investment, and improved the efficiency and focus of special investigation units, claims research, clinicians and adjusters.