Healthcare Insurance Fraud Prevention

Most healthcare insurers verify member identity at enrollment through document collection and verification. A large percentage then fail to bind that verified identity to a strong authentication factor for future confirmation. So, when a member calls, logs in, or submits a claim, the system has no reliable way to authenticate that the person interacting with it is the same person it originally identified.

Fraud vectors active at the identity layer include:

• Medical identity theft: stolen or synthetic identities used to obtain healthcare services, prescriptions, or reimbursements under another person’s coverage, often undetected until the legitimate member receives an unexplained explanation of benefits
• Member impersonation: bad actors using breached PII or AI-generated voice clones to pass knowledge-based authentication in contact center and digital channels, gaining access to benefits, claims, and payment information
• Benefits redirection: unauthorized account access used to redirect reimbursements or alter banking details before legitimate claims are paid
• Prescription fraud: unauthorized access to patient portals or IVR systems used to request, redirect, or manipulate prescription authorizations

The 21st Century Cures Act requires healthcare organizations to provide patients with open, API-based access to their electronic health information. HIPAA requires them to protect that same information from unauthorized disclosure. Meeting both obligations simultaneously requires authentication strong enough to confirm that the person accessing the record is the person it belongs to.

Daon closes the gap between verified identity and authenticated identity by establishing a biometric anchor at enrollment that travels with the member across every channel.

At enrollment, identity documents are validated as genuine, unaltered, and current. Biometric face matching confirms the person presenting the document is the person pictured on it, with Presentation Attack Detection tested by iBeta to ISO 30107-3 Level 2 ensuring the face captured is live and present.

The verified biometric becomes the reference point for all subsequent interactions. Additional authentication factors, including passkeys and voice biometrics, can be bound to that same verified identity at enrollment or at any point in the member lifecycle.

Passkeys can be generated directly from the IDV workflow. Other factors can be confirmed through a face step-up at the time of enrollment, ensuring the verified member is the one binding each new factor.

For routine interactions, lower-friction factors like passkeys can handle login without requiring a biometric challenge at every touchpoint. Where risk is elevated, such as prescription requests, banking detail changes, or claims submissions, the organization can step up to face biometric authentication to confirm the verified member is present at the moment that matters.

In contact center and IVR interactions, enrolled voiceprints authenticate callers against their verified identity. Synthetic voice detection confirms the voice is human in real time, regardless of language or cloning model.