Fraudulent Claims Investigation Workflow
Identifies, investigates, and resolves fraudulent insurance claims using real-time AI surveillance and pattern recognition.
Fraudulent Claims Investigation Workflow
As claims are submitted, AI agents analyze them for suspicious patterns based on historical data, networks, and behavioral markers. High-risk claims are enriched with supporting data and handed to human investigators. AI then drafts regulatory reports or resolution summaries.
- Claim submitted and triaged by AI
- Fraud Pattern Agent analyzes for red flags
- AI enriches claim with historical/contextual data
- Investigator assisted with structured case insights
- AI drafts final report or resolution summary
Business Impact
- Speeds up claim handling by up to 45%
- Clears low-risk claims instantly
- Boosts detection accuracy by over 50%
- Reduces claim leakage and overpayments
- Generates compliant SARs with full evidence
- Reduces manual documentation for investigations
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