Workers' Comp Fraud Investigator
Identify workers' comp fraud patterns and prioritize investigations by risk
What You Can Do
Upload claims data and claimant profiles, and Claude analyzes patterns to surface fraud indicators, generates prioritized investigation leads, and assigns risk scores to claims. You'll receive a structured assessment identifying suspicious claim clusters, timeline anomalies, and behavioral red flags that warrant SIU investigation.
Features
Detect unusual patterns across multiple claims—clustering by similar circumstances, timing, provider networks, or claimant behavior to identify organized fraud rings
Assign quantitative risk scores (1-100) to individual claims based on red flag density, historical patterns, and comparative benchmarking against similar claims
Automatically generate prioritized, actionable investigation leads with specific hypotheses, evidence pointers, and recommended next steps for SIU teams
Identify behavioral, temporal, medical, and provider-based red flags—staged accidents, timeline inconsistencies, over-treatment, billing anomalies
Compare suspect claims against industry baselines and portfolio peers to surface statistical outliers (e.g., unusually high medical costs for injury type)
Cross-reference claim dates, medical visits, procedures, and statements for internal contradictions and improbable sequences
Identify connections between claimants, medical providers, attorneys, and employers to spot fraud networks and collusion patterns
Example Output
Claim #WC-2024-087543 — Risk Score: 78/100 (HIGH)
Red Flags Detected:
- Lost-time claim filed 4 days after reported injury (typical delay: 1-2 days)
- 6 medical visits in 2 weeks, same provider (85th percentile for injury type)
- MRI ordered before physical exam (protocol violation)
- Claimant's social media shows activity inconsistent with alleged injury
Investigation Lead: Compare treatment protocol against peer claims for similar back injury. Request utilization review and surveillance recommendation.
Network Finding: Dr. Chen (provider) linked to 12 high-risk claims in past 18 months (vs. 3 for peer providers). Attorney Johnson appears on 8 of those claims. Recommend coordinated SIU review of Dr. Chen cluster.
What's Included
- Fraud Risk Assessment Framework: Structured methodology for evaluating claim-level and network-level fraud probability, aligned with SIU best practices
- Claims Pattern Analyzer: Tool to surface temporal, behavioral, and provider-based patterns across your portfolio or claim cohorts
- Investigation Lead Generator: Produces actionable leads with evidence pointers, risk factors, and recommended investigative approaches
- Red Flag Detection Rules: Comprehensive checklist of medical, behavioral, timing, and network-based indicators of fraud
- Comparative Benchmarking Module: Compare individual claims against industry and portfolio baselines to identify statistical outliers
Who It's For
- SIU Investigators
- Workers' Compensation Fraud Analysts
- Claims Managers & Adjusters
- Insurance Risk Managers
- Workers' Comp Compliance Officers
Best For
- Initial claims screening & triage
- Fraud risk prioritization
- Network & pattern detection
- Investigation roadmap development
- Comparative loss analysis
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