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 – and lack the tools 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 Fraud, Waste, and Abuse (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.

Prevent medical claims leakage with Smart Claims

Safeguard payment integrity through comprehensive detection of Fraud, Waste and Abuse (FWA) in medical claims. Leverage advanced AI-powered analysis that goes far beyond the header-level checks most solutions offer – drilling into claim line-item detail and identifying suspicious behaviour patterns over time.

Spot provider overcharging and diagnosis mismatches, uncover unusual pathology and radiology costs at the line level, and detect hidden collusion through longitudinal behavioural analysis.

See how it works

Why Smart Claims?

Uncover hidden anomalies in each claim line – spot non-payable items, abnormal item quantities or costs, and atypical pathology or radiology charges that header-only tools miss.

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.

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.

Granular Line Item FWA Analysis

Uncover hidden anomalies in each claim line – spot non-payable items, abnormal item quantities or costs, and atypical pathology or radiology charges that header-only tools miss.

Longitudinal Behavioural Profiling

Precise Decision Intelligence

With Smart Claims, you can:

Close gaps in payment integrity by combining header level, line item, and longitudinal FWA detection – and increase your automated medical fraud detection rates by 2-3x.

Speed up claim assessment by up to 50% or more, by equipping assessors with instant, data-driven insights on potentially fraudulent claims – cutting down manual investigation time and improving throughput.

Give assessors the tools to make accurate, justified decisions – backed by precise, line-level AI analysis that continuously adapts to your unique data landscape and fraud patterns.

Reduce Claims Leakage

Close gaps in payment integrity by combining header level, line item, and longitudinal FWA detection – and increase your automated medical fraud detection rates by 2-3x.

Accelerate Adjudication Efficiency

Enhance Decision Transparency

Give assessors the tools to make accurate, justified decisions – backed by precise, line-level AI analysis that continuously adapts to your unique data landscape and fraud patterns.