Photo - Dr. Opinion
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Dr. Opinion

Fraud detection for dental insurance claims

USA, California
Market: Insurance, Artificial Intelligence
Stage of the project: Operating business

Date of last change: 24.09.2020
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Idea

For dental insurance companies that are manually reviewing millions of claims every day to avoid mistakes, abuse, and fraud, Dr. Opinion analyzes images to determine the validity of claims, addressing a $20B global healthcare problem.

Current Status

Prototype launched in April 2020
MVP launched in July 2020
A first pilot (non-paid) started in July 2020
Three pilots (non-paid) started in September 2020
Four pilots (non-paid) starting in October 2020

Market

There are over 250 target customers in the U.S. Our target customers are all health insurance companies that have dental plans in their portfolio such as MetLife and Delta Dental. We interviewed potential customers in the U.S., Brazil, and Korea, and we learned that dental fraud is not happening only in the U.S. but globally.

Our research shows that the insurance fraud market is huge. $390B are lost annually due to health insurance fraud worldwide. Among them, the dental insurance fraud causes $19.5B annual loss globally and $12.5B annual loss in the USA. Health insurers in the United States estimate that about 17% to 20% of their dental claims are fraudulent.

Problem or Opportunity

Every time a patient uses health insurance for dental work, the treating dentist needs to claim the payment from a dental insurer. The insurers usually require information such as procedures, patient data, and images to prove that the treatment has been completed.

It has always been a challenge for dental insurers to review the claims to catch mistakes, abuses, and fraud due to the three main reasons. First, they are receiving millions of claims every day. Second, the treatment reviews are done manually. Third, it is difficult to analyze unstructured data such as images and xrays.

For example, one of the top dental insurance companies in California has a team of +100 dental consultants to analyze dental claims they receive. However, the number is not enough to go through all the claims and images, and, as a result, they auto-approve approximately 90% of all their claims. The problem is serious, causing $12.5B loss on fraud in the dental insurance sector in the U.S. market alone.

Solution (product or service)

Supported by pre-trained models with machine learning, the Dr. Opinion platform analyzes images to determine the validity of dental insurance claims. Our patent-pending technology performs various tasks fr om detecting dental treatments within images to finding duplicate images from the past claims history. The main benefits are the automated dental image analysis, the reduction in cost related to fraud, waste, and abuse and human labor, and reduction in time to process each claim. In addition, Dr. Opinion offers an analytics dashboard wh ere the insurers can navigate statistics about the claims data and FWA detected. Through the dashboard, they get insights to improve their operation and products. Overall, our platform will help insurance enterprises to reduce costs and make healthcare affordable for everyone.

Competitors

Every company that applies AI to analyze dental images is our potential competitor.
- Pearl (https://hellopearl.com/)
- VideaHealth (https://www.videahealth.io/)
- Overjet (https://www.overjet.ai/)
- Retrace (https://retrace.ai/).

Advantages or differentiators

We are the only company that is 100% devoted to the dental fraud problem unlike the competitors who are developing multiple products. We are using all our energy and resources to develop models that are best suited to combat dental insurance fraud, applying computer vision technology and AI in this unique field.

Moreover, our team is composed of international founders with access to global networking opportunities. For instance, Daniel and Ivan, the Brazilian founders, have been able to bring in several insurers in Latin America as our initial prospective customers/piloting companies.

Finance

We will generate revenue by charging transaction fees based on the number of claims analyzed. Each year, about 200M dental claims are processed in the USA. If we charge $2/claim as a transaction fee, with 15% market share in the USA, we would generate $60M ARR. The $2/claim represents 1% of the average claim amount. The transaction fee is flexible up to each customer.

Business model

We have a SaaS, B2B enterprise model. We will get customers through direct sales and strategic partnerships (e.g., claims management system providers).

Money will be spent on

60% Product Development
40% Sales

Team or Management

Risks

Potential risks that we see are:
1. Potential customers building their own solutions internally; and
2. A credibility issue (e.g., customers feel less safe engaging a small company, especially when handling sensitive, medical data). To avoid the credibility issue, we are continuously conducting internal audits and engaged one of reputable HIPAA/Privacy firms for external audits.

Incubation/Acceleration programs accomplishment

- Participation in XLerateHealth (accelerator) - virtual; started in August 2020.
- Participation in NewChip (accelerator; equity-free) - virtual; started in July 2020.

Invention/Patent

We have a non-provisional patent application (16/866503, filed on May 4, 2020).

Photos

Photo 1 - Fraud detection for dental insurance claims
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Idea
Current Status
Market
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Solution (product or service)
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Advantages or differentiators
Finance
Invested in previous rounds, $
Business model
Money will be spent on
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Team or Management
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Risks
Incubation/Acceleration programs accomplishment
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Invention/Patent
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