Automating and Optimizing TrueClaim’s Insurance Claims Workflows with AWS AI

TrueClaim, a modern insurance claims processing company, partnered with TekBay Digital Solutions to harness Generative AI, Machine Learning (ML), and AWS Cloud infrastructure for faster, more accurate, and cost-effective claims processing.

TekBay implemented a solution that automated document understanding, fraud detection, and claims validation, which made processing claims 70% faster. By integrating AWS AI services such as Amazon Textract, Amazon Bedrock, and Amazon SageMaker, TekBay enabled TrueClaim to achieve intelligent, end-to-end claims automation.

Customer’s Challenges:

Before adopting AWS Cloud services, TrueClaim faced several challenges with its legacy systems:

1. Legacy Infrastructure: The previous on-premise setup led to high costs, long innovation cycles, and difficulty in scaling the system to handle increasing claims volumes.
2. Scalability: TrueClaim needed a more flexible, scalable solution that could automatically adjust to fluctuating workloads, especially during peak claim submission periods.
3. Operational Overhead: The management of on-premise infrastructure was cumbersome and resource-heavy, including hardware refresh cycles, power consumption, and manual compliance management.
4. Fraud Prevention & Accuracy: Manual claim verification could not detect anomalies or fraudulent claims accurately and quickly.
5. Customer Experience: Slow claim processing negatively impacted customer satisfaction and increased operational costs.

AWS-Powered Solution by TekBay

TrueClaim transitioned to AWS Cloud with TekBay’s guidance, leveraging AI-driven automation and cloud-native scalability to optimize claims processing, improve fraud detection, and make the system more efficient, scalable, and secure.

Key AWS Services Used:

• Amazon Textract: Automates data extraction from unstructured documents, reducing manual processing time.
• Amazon Bedrock (GPT-OSS-20B Model): Provides advanced natural language processing (NLP) for document analysis and fraud detection.
• Amazon SageMaker: Custom fraud detection models are trained and deployed using SageMaker, which helps identify suspicious patterns and flag potentially fraudulent claims more efficiently.
• AWS Lambda: Serverless compute functions for processing claims and invoking machine learning models. that scale automatically with demand.
• Amazon API Gateway: Manages APIs for document ingestion, validation, and system interactions.
• Amazon S3: Scalable object storage for incoming claim documents and processed data.
• Amazon RDS PostgreSQL (Multi-AZ): Ensures high availability and fault tolerance for transactional claims data.
• Amazon Route 53: DNS management for routing user traffic securely to the appropriate endpoints.
• AWS WAF & ALB: Secure the application and balance traffic across multiple availability zones.
• Terraform: Automates infrastructure provisioning and management using Infrastructure-as-Code (IaC).
• Amazon CloudWatch & SNS: Enables centralized monitoring, logging, and real-time alerts for performance and failure management.

Architecture Diagram Overview

The solution architecture includes the following core components:

• VPC with multiple availability zones to ensure high availability.
• AWS Lambda for event-driven, serverless compute functions.
• Amazon S3 for document storage and model outputs.
• Amazon Bedrock and SageMaker for machine learning model training and inference.
• RDS PostgreSQL for storing structured data in a highly available, fault-tolerant database setup.
• Amazon CloudWatch and SNS for real-time monitoring and alerting.

How AWS Services Addressed the Challenges?

1) Scalability & High Availability:

The platform dynamically scales to handle varying volumes of claims, document submissions, and model evaluations:

• Amazon S3 provides virtually unlimited storage for incoming and processed documents.
• AWS Lambda executes serverless functions that automatically scale based on workload.
• Amazon RDS PostgreSQL (Multi-AZ) ensures fault-tolerant, highly available database operations.
• Amazon SageMaker Pipelines scale horizontally, delivering consistent performance for model training and inference.
• Amazon API Gateway automatically scales to manage API requests from multiple clients.

2) Failure Management:

The architecture is resilient to localized failures, ensuring continuous operation:

• Multi-AZ RDS and ALB maintain service even during zone outages.
• Amazon CloudWatch and SNS provide real-time monitoring and alerts to detect and resolve service issues quickly.

3) Fraud Detection & Verification:

By utilizing Amazon Bedrock’s GPT-OSS-20B model for document analysis and Amazon SageMaker for custom fraud detection models, the system can process documents more efficiently and accurately, quickly flagging potential fraudulent claims.

4) Security & Compliance:

The system ensures that claims data is encrypted using AWS KMS, and access is tightly controlled through AWS IAM. This meets regulatory requirements such as HIPAA, GDPR, and PCI-DSS, ensuring sensitive data is protected.

5) Automation & Efficiency:

The integration of serverless compute with AWS Lambda reduces operational overhead and accelerates the processing of claims by automating manual tasks. Claims are processed faster and with fewer resources, improving overall efficiency.

6) Cost Efficiency:

The transition to AWS reduced the need for on-premises hardware and the associated costs, including power, cooling, and maintenance. The use of serverless and managed services significantly cuts down on operational costs and allows TrueClaim to focus on core business activities.

Results And Success Metrics

The AWS-powered, AI-driven solution delivered measurable improvements across TrueClaim’s operations, impacting speed, cost, accuracy, and customer satisfaction:

• Improved Claims Resolution Time: By automating document processing and fraud detection, TrueClaim Pro has been able to reduce claims lifecycle times by 70%, significantly speeding up the claims handling process.
• Cost Reduction: Moving to AWS has eliminated the need for on-premise hardware and related maintenance costs, and the use of serverless and managed services has further reduced operational overhead.
• Fraud Detection: The integration of Amazon Bedrock’s GPT-OSS-20B model for document analysis and verification and custom SageMaker model has enhanced fraud detection, identifying fraudulent claims with greater speed and accuracy has improved fraud detection capabilities.
• Operational Efficiency: Automation reduced manual tasks, cutting down processing costs and increasing throughput. The system’s flexibility supports the rapid onboarding of new models, ensuring faster innovation.
• Customer Satisfaction: The ability to process claims faster and more accurately has improved customer satisfaction and retention.

Lesson Learned From TrueClaim’s AWS And AI Transformation

The implementation of a cloud-native, AI-powered claims processing platform offered several strategic insights:

• Plan for Dynamic Scaling: Architecting with serverless and multi-AZ resources ensures the system can automatically handle peaks in demand without overprovisioning.
• Automate for Accuracy and Speed: Leveraging AI/ML models like Amazon Bedrock and SageMaker reduces human error and accelerates workflows.
• Prioritize Security and Compliance: Integrating AWS KMS and IAM from the outset safeguards sensitive data while meeting regulatory requirements.
• Monitor Continuously for Reliability: Real-time monitoring and alerting (CloudWatch + SNS) enable proactive detection and resolution of issues.

Future Expansion Plans

• Multi-Region Deployment:
  • As TrueClaim expands its operations, the company plans to extend its solution to multiple AWS regions to ensure low-latency access to customers around the globe.
• Model Enhancements:
  • Future improvements will focus on optimizing fraud detection models and enhancing document processing capabilities using the latest advancements in AI and ML.
• Full Automation of Claims Lifecycle:
  • The company aims to fully automate the entire claims lifecycle, from submission to settlement, to further streamline processes and reduce operational costs.

Conclusion

Therefore, by adopting a cloud-native, AI-powered claims processing platform on AWS, TrueClaim transformed insurance claims processing. The system offers scalability, security, and efficiency, delivering measurable business value through cost reduction, faster claim resolution, and enhanced fraud detection. TrueClaim is positioned for ongoing growth and innovation, sustaining its competitive advantage.