Route Insurance Fraud Cases to SIU
A claim flagged with fraud indicators — whether by red-flag detection scoring, an adjuster's own suspicion, or an external tip — needs to reach the special investigations unit with enough evidence context for an investigator to actually open the case efficiently, but in practice referrals often arrive as a bare flag with a one-line reason, leaving the SIU investigator to reconstruct the claim's history and evidence from scratch before real investigative work can even start. Cases also don't always route to the investigator with the right specialization — a suspected staged-collision ring case handled by an investigator experienced in medical billing fraud, for instance — which slows the case down at exactly the stage where momentum and fresh evidence matter most.
STARTING PRICE
From €799
Complex tier · Multi-system orchestration, custom logic, and higher-volume or higher-risk processing.
Get a quote →Saves roughly 3-6 hrs per case in evidence compilation and routing turnaround.
How the automation works
We compile a structured case package from every fraud-flagged claim — the specific red flags triggered, relevant claim history, prior claims by the same parties if any, and supporting documentation — before it reaches SIU, so an investigator opens a case with real context instead of a bare referral. Cases are routed to the investigator with relevant case-type specialization based on the flagged fraud pattern (staged collision, medical billing anomaly, arson indicators, application fraud), and case priority is set by a combination of claim value and evidence strength, not just flag volume. No case is closed, denied, or escalated to a formal fraud referral (such as to a regulator or law enforcement) automatically — the investigator's actual investigation, conclusion, and any external referral decision remain entirely a human process; this only accelerates getting a well-documented case to the right investigator quickly.
Process flow
- 01
Claim flagged for suspected fraud trigger
A claim flagged through red-flag detection scoring, adjuster referral, or an external tip enters SIU case package compilation.
- 02
Compile structured case package ai
The specific triggered red flags, relevant claim and party history, prior claims involving the same parties, and supporting documentation are compiled into a structured case package rather than a bare flag notification.
- 03
Classify fraud pattern type ai
The suspected fraud pattern is classified — staged collision, medical billing anomaly, arson indicator, application fraud, or other — based on the specific evidence and flags present.
- 04
Route to investigator with relevant specialization output
The case routes to the SIU investigator with relevant specialization for the classified fraud pattern type, rather than a generic queue or whoever's next in rotation.
- 05
Set case priority ai
Case priority is set combining claim value and evidence strength, so a high-value claim with strong supporting evidence gets attention ahead of a lower-value case with a single weak indicator.
- 06
Hand off for human investigation output
The compiled, classified, prioritized case is handed to the investigator for the actual investigation — nothing about the investigative conclusion, claim denial, or external fraud referral is automated.
Inputs
- Fraud-flagged claim data and triggering red flags
- Claim and party history (including prior claims)
- SIU investigator specialization mapping
- Supporting claim documentation
Outputs
- Structured case package per flagged claim
- Fraud-pattern-classified, specialization-routed case assignment
- Priority-ranked SIU case queue
- Case compilation and routing audit log
Works with
Prefer a fully custom build instead of an off-the-shelf integration? We scope both options during your free consultation — most jobs like this one work fine on standard connectors, but higher-volume or non-standard systems sometimes need bespoke API work, reflected in the complex tier.
Where this goes wrong if you get it wrong
- A case package compiled from automatically flagged red flags can present circumstantial patterns with more apparent certainty than they deserve — a claim history that looks unusual can have an entirely legitimate explanation, and the package needs to present evidence as exactly that, evidence to investigate, not a pre-formed conclusion the investigator is being nudged to confirm.
- Routing by classified fraud-pattern type depends on that classification being accurate, and a case misclassified — a genuinely staged-collision case tagged as application fraud, for instance — routes to an investigator without the relevant specialization, which can slow the case down more than a generic routing would have, since the investigator has to first recognize the misclassification.
- No claim should be denied, closed, or referred externally to a regulator or law enforcement based on this routing and packaging process alone — that entire determination is the SIU investigator's professional judgment following their actual investigation, and treating the initial fraud-flag evidence as sufficient on its own for any of those actions skips the investigation the case package is meant to support, not replace.
- Prior claims by the same parties are a legitimate investigative signal, but matching parties across claims needs care — common names, shared addresses in multi-unit buildings, or family members with separate legitimate claims can create false pattern matches that look like a repeat-claimant signal but aren't, and an investigator needs that context flagged as uncertain, not presented as a confirmed link.
Frequently asked questions
Does this decide whether a claim is actually fraudulent?
No — it compiles evidence and routes the case to the right investigator. The actual investigation, conclusion, and any decision to deny a claim or refer it externally remain entirely the SIU investigator's professional judgment.
How does it decide which investigator gets a case?
Cases are routed based on the classified fraud pattern — staged collision, medical billing anomaly, arson indicators, application fraud — matched to investigators with relevant specialization in that pattern type, rather than a generic queue.
Does it flag prior claims by the same parties even if that match could be wrong?
Yes, but flagged as a potential match requiring investigator verification, not a confirmed link — common names or shared addresses can create false matches, and that uncertainty is preserved for the investigator to check.
What makes a case higher priority in the SIU queue?
A combination of claim value and evidence strength, so cases with both meaningful financial exposure and solid supporting evidence get attention ahead of lower-value or weakly-evidenced cases, rather than ranking purely by when the flag was raised.