AI Fraudulent Claim Investigation
AI Fraudulent Claim Investigation
Uncover fraud patterns in your claims data
Uncover fraud patterns in your claims data
V7 Go's agent assists Special Investigations Units (SIUs) by analyzing claims documents to flag suspicious activities identify inconsistencies and surface patterns of fraud waste and abuse.
What is it
What is it
Investigating Suspicious Claims
A fraudulent insurance claim is a deceptive attempt to collect money from an insurer for a loss that was not covered was exaggerated or never happened.
How is it solved today?
SIU investigators manually review claim files looking for red flags and trying to connect disparate pieces of information a process that is slow and often misses complex fraud rings.
How is it solved today?
SIU investigators manually review claim files looking for red flags and trying to connect disparate pieces of information a process that is slow and often misses complex fraud rings.
How is it solved today?
SIU investigators manually review claim files looking for red flags and trying to connect disparate pieces of information a process that is slow and often misses complex fraud rings.
Why V7 Go
V7 Go automates the analysis of all claim documents identifying inconsistencies suspicious provider networks and other fraud indicators across thousands of claims at once.
Why V7 Go
V7 Go automates the analysis of all claim documents identifying inconsistencies suspicious provider networks and other fraud indicators across thousands of claims at once.
Why V7 Go
V7 Go automates the analysis of all claim documents identifying inconsistencies suspicious provider networks and other fraud indicators across thousands of claims at once.
Time comparison
Time comparison
Time comparison
Traditional way
4-8 hours
4-8 hours
With V7 Go agents
15-30 minutes
15-30 minutes
Average time saved
95%
95%
Why V7 Go
Analyze claim files, medical reports, and witness statements.
Identify inconsistent timelines, unusual patterns, and fraud indicators.
Workflow
Workflow
Import your files
Guidewire
,
Duck Creek Claims
,
Salesforce
First Notice of Loss (FNOL)
First Notice of Loss (FNOL)
First Notice of Loss (FNOL)
Medical Reports & Billing
Medical Reports & Billing
Medical Reports & Billing
Police & Incident Reports
Police & Incident Reports
Police & Incident Reports
Witness Statements
Witness Statements
Witness Statements
Damage Photographs & Estimates
Damage Photographs & Estimates
Damage Photographs & Estimates
Social Media & Public Records
Social Media & Public Records
Social Media & Public Records
Inconsistent Timelines or Statements
Inconsistent Timelines or Statements
Inconsistent Timelines or Statements
Unusual Medical Treatment Patterns
Unusual Medical Treatment Patterns
Unusual Medical Treatment Patterns
Links to Known Fraudulent Providers
Links to Known Fraudulent Providers
Links to Known Fraudulent Providers
Prior Claims History Matches
Prior Claims History Matches
Prior Claims History Matches
Mismatched Damage Reports
Mismatched Damage Reports
Mismatched Damage Reports
Suspicious Witness Connections
Suspicious Witness Connections
Suspicious Witness Connections
Address/Phone Number Overlap
Address/Phone Number Overlap
Address/Phone Number Overlap
Anomalous Billing Codes
Anomalous Billing Codes
Anomalous Billing Codes
Contradictory Public Information
Contradictory Public Information
Contradictory Public Information
Use of Post Office Boxes
Use of Post Office Boxes
Use of Post Office Boxes
Why V7 Go
Why V7 Go
Pattern & Anomaly Detection
Analyze thousands of claims to identify suspicious patterns such as multiple claims from the same address or unusual treatment protocols from a specific medical provider.
Pattern & Anomaly Detection
Analyze thousands of claims to identify suspicious patterns such as multiple claims from the same address or unusual treatment protocols from a specific medical provider.
Pattern & Anomaly Detection
Analyze thousands of claims to identify suspicious patterns such as multiple claims from the same address or unusual treatment protocols from a specific medical provider.
Cross-Claim Analysis
Connect disparate data points across multiple claim files to uncover organized fraud rings that would be invisible when looking at one claim at a time.
Cross-Claim Analysis
Connect disparate data points across multiple claim files to uncover organized fraud rings that would be invisible when looking at one claim at a time.
Cross-Claim Analysis
Connect disparate data points across multiple claim files to uncover organized fraud rings that would be invisible when looking at one claim at a time.
Evidence Link Analysis
Create a visual map of relationships between claimants providers witnesses and locations to highlight non-obvious connections and potential collusion.
Evidence Link Analysis
Create a visual map of relationships between claimants providers witnesses and locations to highlight non-obvious connections and potential collusion.
Evidence Link Analysis
Create a visual map of relationships between claimants providers witnesses and locations to highlight non-obvious connections and potential collusion.
Social Media & Web Research
The agent compares statements from different parties or different documents within the same claim to flag contradictions in the timeline or description of events.
Social Media & Web Research
The agent compares statements from different parties or different documents within the same claim to flag contradictions in the timeline or description of events.
Social Media & Web Research
The agent compares statements from different parties or different documents within the same claim to flag contradictions in the timeline or description of events.
Social Media & Web Research
Use AI web search to find publicly available information that may contradict the claim such as a claimant's social media posts showing activities inconsistent with their reported injuries.
Social Media & Web Research
Use AI web search to find publicly available information that may contradict the claim such as a claimant's social media posts showing activities inconsistent with their reported injuries.
Social Media & Web Research
Use AI web search to find publicly available information that may contradict the claim such as a claimant's social media posts showing activities inconsistent with their reported injuries.
Automated Red Flag Scoring
Generate a 'fraud risk score' for each claim based on a customizable set of red flags allowing your SIU team to prioritize its investigative resources.
Automated Red Flag Scoring
Generate a 'fraud risk score' for each claim based on a customizable set of red flags allowing your SIU team to prioritize its investigative resources.
Automated Red Flag Scoring
Generate a 'fraud risk score' for each claim based on a customizable set of red flags allowing your SIU team to prioritize its investigative resources.
V7 Go
V7 Go
V7 Go
AI-powered fraud detection
AI-powered fraud detection
for insurance SIUs
Investigating fraudulent claims requires manually sifting through mountains of documents to find subtle inconsistencies and connections—a task that is nearly impossible to do at scale. SIU teams are overwhelmed and sophisticated fraud schemes often go undetected. V7 Go's AI agent acts as a powerful analytical assistant processing thousands of documents to connect data points and flag suspicious patterns that indicate potential fraud.
Special Investigations Units (SIU)
Amplify your team's effectiveness by automating the initial analysis of claims files. Let AI find the red flags so your investigators can focus on building cases.
Special Investigations Units (SIU)
Amplify your team's effectiveness by automating the initial analysis of claims files. Let AI find the red flags so your investigators can focus on building cases.
Special Investigations Units (SIU)
Amplify your team's effectiveness by automating the initial analysis of claims files. Let AI find the red flags so your investigators can focus on building cases.
Claims Managers
Gain a portfolio-wide view of fraud risk and trends. Make data-driven decisions on where to deploy investigative resources for the greatest impact.
Claims Managers
Gain a portfolio-wide view of fraud risk and trends. Make data-driven decisions on where to deploy investigative resources for the greatest impact.
Claims Managers
Gain a portfolio-wide view of fraud risk and trends. Make data-driven decisions on where to deploy investigative resources for the greatest impact.
Delegate claim investigation
Delegate claim investigation
to an SIU AI agent
to an SIU AI agent
Pattern & Anomaly Detection
Analyze thousands of claims to identify suspicious patterns such as multiple claims from the same address or unusual provider billing.
Cross-Claim Analysis
Connect disparate data points across multiple claim files to uncover organized fraud rings that would be invisible when looking at one claim at a time.
More agents
Next steps
Stop searching for needles in a haystack.
Let's talk
You’ll hear back in less than 24 hours
Next steps
Stop searching for needles in a haystack.
Let's talk
Next steps
Stop searching for needles in a haystack.
Let's talk
You’ll hear back in less than 24 hours
FAQ
FAQ
FAQ
Have questions?
Find answers.
What is insurance fraud?
Insurance fraud involves any act committed with the intent to deceptively obtain payment from an insurer ranging from exaggerated claims to organized criminal schemes.
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What is insurance fraud?
Insurance fraud involves any act committed with the intent to deceptively obtain payment from an insurer ranging from exaggerated claims to organized criminal schemes.
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What is insurance fraud?
Insurance fraud involves any act committed with the intent to deceptively obtain payment from an insurer ranging from exaggerated claims to organized criminal schemes.
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How does the AI agent detect fraud?
The agent uses a combination of rules-based flagging and machine learning to spot anomalies. It looks for known red flags and analyzes data across thousands of claims to find new patterns of suspicious behavior.
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How does the AI agent detect fraud?
The agent uses a combination of rules-based flagging and machine learning to spot anomalies. It looks for known red flags and analyzes data across thousands of claims to find new patterns of suspicious behavior.
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How does the AI agent detect fraud?
The agent uses a combination of rules-based flagging and machine learning to spot anomalies. It looks for known red flags and analyzes data across thousands of claims to find new patterns of suspicious behavior.
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Can the agent analyze unstructured data like adjusters' notes?
Yes this is a key strength. The agent reads and understands narrative text to find inconsistencies identify suspicious phrasing and extract key entities to build a relationship map.
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Can the agent analyze unstructured data like adjusters' notes?
Yes this is a key strength. The agent reads and understands narrative text to find inconsistencies identify suspicious phrasing and extract key entities to build a relationship map.
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Can the agent analyze unstructured data like adjusters' notes?
Yes this is a key strength. The agent reads and understands narrative text to find inconsistencies identify suspicious phrasing and extract key entities to build a relationship map.
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Does the agent make the final decision on a claim's validity?
No. The agent is an investigative assistant. It surfaces evidence flags inconsistencies and highlights suspicious patterns for a human investigator. The final judgment always rests with the SIU professional.
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Does the agent make the final decision on a claim's validity?
No. The agent is an investigative assistant. It surfaces evidence flags inconsistencies and highlights suspicious patterns for a human investigator. The final judgment always rests with the SIU professional.
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Does the agent make the final decision on a claim's validity?
No. The agent is an investigative assistant. It surfaces evidence flags inconsistencies and highlights suspicious patterns for a human investigator. The final judgment always rests with the SIU professional.
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How is this different from existing fraud analytics tools?
Many existing tools are rules-based and only look at structured data. V7 Go's agent is different because it analyzes unstructured documents and uses AI to find non-obvious connections.
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How is this different from existing fraud analytics tools?
Many existing tools are rules-based and only look at structured data. V7 Go's agent is different because it analyzes unstructured documents and uses AI to find non-obvious connections.
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How is this different from existing fraud analytics tools?
Many existing tools are rules-based and only look at structured data. V7 Go's agent is different because it analyzes unstructured documents and uses AI to find non-obvious connections.
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Can we customize the fraud indicators the agent looks for?
Absolutely. Your SIU team can configure the agent's workflow with your own red flags and risk scoring parameters tailoring the system to the specific fraud schemes common in your line of business.
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Can we customize the fraud indicators the agent looks for?
Absolutely. Your SIU team can configure the agent's workflow with your own red flags and risk scoring parameters tailoring the system to the specific fraud schemes common in your line of business.
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Can we customize the fraud indicators the agent looks for?
Absolutely. Your SIU team can configure the agent's workflow with your own red flags and risk scoring parameters tailoring the system to the specific fraud schemes common in your line of business.
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