Claims fraud
Claims that share the details of a claim you already paid.
Staged losses and provider rings are organised, and organisation leaves repeats: one phone across three claimants, one bank account under two names, one repair estimate submitted twice with the header changed.
The problem
What this is for
An adjuster sees one claim at a time and has minutes for it. A ring is only visible across claims, months apart, in different offices. The details that link them are already in the file: the phone on the first notice, the account the payment went to, the hash of the estimate that was uploaded.
The workflow
8 stages, and what runs where
Each stage names the module behind it. The chip says whether it runs on your network or ours.
- In your systems
- 2 stages
- At intake
- 2 stages
- On the platform
- 3 stages
- With a person
- 1 stage
- In your systems
A claim is filed, and again when it changes
Your claims system posts the claim, the claimant, the policy and the provider, keyed on your own claim number.
- In your systems
Documents are posted as hashes
The content stays in your system. What crosses is a hash and the metadata, which is enough to see the same estimate arrive twice.
- At intake
The event is accepted or refused, in writing
A claim about a policy nobody is monitoring is recorded with that reason, so a gap in coverage reads as a gap rather than as a quiet month.
- At intake
The details join the ledger
Phones, addresses, accounts and document hashes are appended against the claimant and the provider, with the claim they came from.
- On the platform
The cross-reference runs across your own book
A value under a second claimant, a document under a second claim, a provider on an unusual share of a claimant's history. Each writes one sentence with its evidence.
- On the platform
Evidence accumulates on the claim and the parties
A claimant carries their own history, and the claim in front of your investigator shows the pooled picture rather than only what arrived today.
- On the platform
A case opens for the investigations queue
Above the floor you set. A second finding on the same claim joins the case rather than opening another.
- With a person
An investigator decides
Confirmed, not fraud, or inconclusive. Nothing here denies a claim, and no coverage decision is made or implied by a band.
What it runs on
Carriers, TPAs, MGAs, and program administrators, on the insurance and claims configuration. Verticals are settings over one platform, never separate products.
You supply the claims
Claims, claimants, providers, policies, payments and document hashes, from the systems that already hold them.
We supply the ledger and the rules
The identity history across your book, the published rules, the case queue and the audit record of every decision.
Your system keeps the file
A flag is a webhook annotating your claim. Reserves, payments and denials are decisions your own system and your own people make.
Why this shape
What the design buys
It sees across claims and offices
The link an adjuster cannot see from one file is the whole of what this looks for.
The file stays where it is
Documents cross as hashes. The platform can say the same document arrived twice without ever holding it.
Findings are sentences, not scores
An investigator opening a case reads what was found and where, which is what a file note has to be able to quote.
Limits
What it refuses
Stated here rather than found later. Each of these is enforced somewhere in the code, not only written on a page.
A shared detail is often innocent
Households, clinics and body shops share phones and addresses legitimately. A value shared by too many stops linking anything.
It is not a coverage opinion
Nothing here reads a policy, values a loss, or has a view on whether a claim is payable. It says where the details have been before.
No claimant hears from us
No reason, no score, and no notice reaches a claimant from this platform. What is said, and by whom, stays yours.
Read next
Where to go from here
Insurance and claims
What the platform reads, and what comes back.
Application fraud
The same cross-reference, pointed at onboarding.
Trust and procurement
What is held, what is not, and how to buy it.
The other analyzers
Carrier identity, Double brokering and Application fraud, on the same ledger and the same pipeline.