Pearl introduces AI software for dental insurance companies

January 29, 2020

Dental AI company Pearl announced two new breakthrough software products in the application of AI and computer vision to processing dental insurance claims, the company announced in a statement this week.

Dental AI company Pearl announced two new breakthrough software products in the application of AI and computer vision to processing dental insurance claims, the company announced in a statement this week.

The company launched GA, the first two Pearl AI software solutions for dental insurance companies are Pearl Claims Approval and Pearl Protect. Pearl has been able to uncover a persistent fraud trend across several national dental insurers, the statement said. It 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, the company reported. These findings suggest that of the $250 billion spent on dental care annually in the U.S., up to seven percent is lost to 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 reseek 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, Pearl CEO and founder. "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 signicant vulnerabilities for insurers, for patients and for the vast majority of dental providers who are good actors.   

Pearl Protect is designed to flag claims when a 2D image is a duplicate or near duplicate of an existing claim. If a dental insurer receives a claim and supporting proof (imagery, x-rays, etc.) from a provider, for example, 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 that the claim in question 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 or supportive scans relative to the claim. If an insurer receives a claim and supporting proof, Claims Approval conducts a visual analysis of imagery morphology and defects, applies a heuristic engine to compare defects against what constitutes a valid claim, and then recommends claims routing based on prevalence and consensus of detected defects.

Automatic approvals for the strongest claims is said to cut down on the 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 10 percent of the claims that truly require more scrutiny, eliminating abuse and fraud.

For more information, visit hellopearl.com.