Smart Claims: AI-Enabled Fraud Waste Abuse Detection in Medical Claims

Smart Claims enables you to safeguard payment integrity through comprehensive detection of Fraud, Waste, and Abuse (FWA) in medical claims.

Healthcare payors often struggle to identify improper utilisation of medical services – lacking the tools required to effectively identify and prevent claims leakage. Most systems rely on static rules or surface-level anomaly detection, flagging suspicious claims based only on high-level totals or statistical outliers. This makes it difficult to spot FWA hidden within unstandardised claim line data that varies widely across providers. Evolving fraud patterns, such as collusion between providers and patients, also go undetected without intelligent context-aware analysis that can profile behavioural patterns over time and across claims.

Smart Claims stops medical claims leakage by leveraging advanced AI-powered analysis that go far beyond the header-level checks most solutions offer – drilling into claim line-item detail and identifying suspicious behaviour patterns over time. It also spots provider overcharging and diagnosis mismatches, uncovers unusual pathology and radiology costs at line level, and detects hidden collusion through longitudinal behavioural analysis.

Why Smart Claims?

• Granular Line Item FWA Analysis – Uncover hidden anomalies in each claim line, spotting non-payable items, abnormal item quantities or costs, and atypical pathology or radiology charges that header-only tools miss.
• Longitudinal Behaviour Profiling – Analyse patterns across time to detect evolving fraud schemes: identify serial over billers, collusive provider-patient behaviour, and policyholder or agent abuse that only emerges across multiple claims.
• Precise Decision Intelligence – Don’t just flag a claim as “suspicious” – Smart Claims clearly identifies which line items triggered concern and explains why. Powered by AI models trained on your market’s data patterns, it delivers transparent, explainable decision recommendations that help assessors act with speed and confidence.

With Smart Claims, you can:

• Reduce Claims Leakage – Close gaps in payment integrity by combining header level, line item, and longitudinal FWA detection, that enables you to increase your automated medical fraud detection rates by ~2-3x.
• Accelerate Adjudication Efficiency – Speed up claim assessment by 50%, by equipping assessors with instant, data-driven insights on potentially fraudulent claims, cutting down manual investigation time and improving throughput.
• Enhance Decision Transparency – Give assessors the tools required to make accurate, justified decisions, backed by precise, line-level AI analysis that continuously adapts to your unique data landscape and fraud patterns.