Fraud Detection

Monitor and investigate fraudulent claims

Total Alerts

4

Open Alerts

2

Critical

1

Active Investigations

1

Confirmed Fraud

1

Duplicate Claim Detection

HIGH
OPEN
CLM2025121900005•Score: 85%

Similar claim submitted for same member within 30 days with same diagnosis

Detected: 19 Dec 2025, 08:00 am
Recommended: Investigate
View Claim

Amount Threshold Breach

MEDIUM
INVESTIGATING
CLM2025121800012•Score: 65%

Claimed amount exceeds 3x the average for similar procedures

Detected: 18 Dec 2025, 02:00 pm
Recommended: Review
View Claim

Provider Billing Spike

CRITICAL
OPEN
CLM2025121700008•Score: 92%

Provider submitted 5x more claims than usual this month

Detected: 17 Dec 2025, 10:00 am
Recommended: Investigate Immediately
View Claim

Phantom Billing Suspected

HIGH
CONFIRMED
CLM2025121500003•Score: 78%

Services billed without corresponding admission records

Detected: 15 Dec 2025, 09:00 am
Recommended: Investigate
View Claim