ClaimShield AI — Fraud & Payment Integrity

Stop fraud
before payment
is released.

ClaimShield AI is the cognitive intelligence layer between claims submission and payment — scoring every claim across clinical, financial, behavioural, network, and document-driven fraud signals in real time.

ClaimShield AI — Live Detection
14,392
Claims today
↑6.4%
247
Flagged high-risk
94% caught
₹8.2M
Blocked pre-pay
This month
Live Fraud Alerts
#CLM-8821Duplicate billing — Cardiology
Risk 98BLOCKED
#CLM-8819Upcoding anomaly — Procedure 99
Risk 87FLAGGED
#CLM-8814Unbundling pattern — Lab cluster
Risk 72REVIEW
#CLM-8809Within benchmark — Clean claim
Risk 22CLEARED
High
Detection accuracy
Strong
Pre-payment block
Post Claim
Audit capability
Low
False positive rate
The Challenge

Fraud is evolving.
Your defences aren’t.

Static rules and manual investigations can’t keep pace. Organised fraud rings adapt faster, document manipulation goes undetected, and investigators are overwhelmed.

Major
Billing Fraud
annual losses from billing fraud
Duplicate Billing
Same claim submitted multiple times — across payors, periods, or with minor variations to evade detection.
Upcoding & Unbundling
Procedures billed at inflated codes or artificially split across claims to maximise reimbursement.
Payment Leakage
Systematic billing above negotiated rates, tariff manipulation, and duplicate adjudication at scale.
Significant
Provider Fraud
share of claims involve provider fraud
Ghost Providers
Non-existent or inactive facilities billing for services never rendered to real patients.
Referral Rings & Collusion
Coordinated provider networks inflating claims through organised kickbacks and cross-referrals.
Provider Abuse
Medically unnecessary procedures, inflated stay durations, and surgical over-indication billed systematically.
Majority
Document & Process
missed by traditional rule engines
Document Manipulation
Forged, altered, or AI-generated medical records and bills submitted to support fraudulent claims.
Excessive Utilisation
Medically unjustified investigations, repeat procedures, and unnecessary hospitalisations billed at scale.
Investigation Bottlenecks
Manual case-building consumes the majority of investigator time — fraud escapes while teams gather data.
Recognise any of these? See how ClaimShield AI stops each one.
A 30-minute demo built around your fraud exposure — duplicate billing, provider abuse, document manipulation, and more.
Book a Demo
ClaimShield AI

The intelligence layer between claims and payment.

ClaimShield AI continuously monitors every claim before payment is released — combining rule-based guardrails with cognitive AI that learns and adapts as fraud patterns evolve.

Clinical Rules Engine

AMA-aligned 7.5M+ rules, ICD/CPT global validation, unbundling and upcoding prevention applied to every claim.

Cognitive AI Detection

Deep neural networks identify document fraud, forgery, AI-generated content, and emergent billing patterns.

Syndicate Analysis

Maps provider-policyholder-intermediary nexus to surface referral rings and organised collusion networks.

Provider Risk Profiling

Dynamic risk scores built from billing history, fraud indicators, and network connections — applied across every provider in the network.

Investigation Workbench

SIU cases built automatically — AI rationale, evidence, provider profile, and similar historical cases in one view.

Payment Integrity Gate

The majority of detected fraud blocked before payment release. Full regulatory audit trail auto-generated per decision.

Detection Flow

From claim submission
to payment decision.

Five stages. Every claim. Completed before a single rupee is released.

Ingestion
Data Ingestion & Normalisation

Every claim enters the ClaimShield AI pipeline — digital submissions, EDI feeds, scanned documents, or manual entries — normalised across hundreds of fields before any analysis begins.

How — ENIGMA extracts structured data from any format including handwritten forms and images. Zero unscreened claims, full data fidelity from the first step.
Outcome — Every claim fully digitised and categorised before reaching the intelligence layers.
Rapid · Ingestion time
Rules Validation
Clinical Rules Engine — 7.5M+ AMA Rules

AMA-aligned clinical rules, ICD/CPT global validation, unbundling prevention, and gender/age mismatch checks applied across every claim in milliseconds.

How — Hard-logic clinical validation across millions of medical standard protocols. Fully configurable per insurer, product, and regulatory environment.
Outcome — Duplicate billing, upcoding, unbundling, and coding errors caught before reaching the AI layer.
7.5M+ · AMA-aligned rules
Cognitive AI
Deep Neural Networks — Document & Pattern

Document digitisation, real-time forgery detection, overwriting and AI manipulation checks — combined with syndicate analysis mapping provider-policyholder-intermediary nexus.

How — Deep neural networks trained on extensive claims data. Identifies emergent fraud patterns — document fraud, ghost providers, referral rings — that rules never surface.
Outcome — High detection accuracy. Catches the sophisticated schemes that pass through every earlier defence.
High · Detection accuracy
Risk Scoring
Fraud Probability Score — 0 to 100

Every claim receives a composite fraud probability score combining rule violations, AI signals, document integrity, and network risk — generated in milliseconds.

How — Ensemble scoring model across all intelligence layers. Score is fully explainable — investigators see exactly which signals triggered each rating.
Outcome — Clear, actionable risk classification: high-risk blocked, medium-risk reviewed, low-risk auto-approved.
Fast · Scoring time
Decision
Pre-Payment Block, Review, or Clear

Final routing: auto-approve clean claims, route high-risk claims to SIU with complete AI-built case files, or block confirmed fraud before payment releases.

How — Full audit trail generated automatically. Investigation workbench dashboards surface all evidence, similar cases, and AI rationale in one unified view.
Outcome — The majority of detected fraud blocked before payment. Investigation time significantly reduced versus manual processes.
High · Pre-payment block
Proven Outcomes Across Global Operations

Measurable impact on fraud, operations, and payment integrity.

Proven outcomes across MENA and South Asia insurance markets.

High
Fraud Detection Rate
Significant improvement over rules-only baseline
Low
False Positive Rate
Precision-tuned to minimise operational disruption
Fast
Investigation Turnaround
Dramatically reduced from manual baseline
Improved
Recovery Rate
More fraud recovered post-payment
High
Pre-Payment Block Rate
Fraud stopped before payment exits
See these outcomes applied to your portfolio.
Our solutions team builds the ROI case around your actual fraud exposure and claim volumes.
Book a Demo
Broad
Coverage reach
Extensive
Claims screened
Significant
Fraud prevented
Global
Reach
Experienced
Track record

See ClaimShield AI protecting your claims in real time.

Our team will walk you through a demo built around your exact claim volumes, fraud patterns, and regulatory environment — not a generic slide deck.

Book a Personalised Demo
No commitment required
Tailored to your fraud profile
Response within 24 hours