Agentic AI in Fraud, Waste & Abuse (FWA) Insurance Claims
Glacien AI flags fraudulent claims with 80-90% accuracy — reducing FWA leakage by $18M+ annually.
The $90B Problem in Insurance
5-10%
of claims involve fraud
Fraudulent Claims Are Draining Your Bottom Line
Industry data shows that 5-10% of insurance claims involve fraud, waste, or abuse — often missed by manual review processes. This translates to billions in losses annually across the insurance industry.
Traditional fraud detection methods rely on rule-based systems and manual reviews that are slow, inconsistent, and easily circumvented by sophisticated fraud schemes. Meanwhile, legitimate claims get delayed in the review process, frustrating customers and damaging your brand.
The result? Major financial losses, increased premiums, regulatory scrutiny, and poor customer experience.
How Glacien's Agentic AI Detects Fraud
Our AI doesn't just follow rules — it learns, adapts, and investigates like an experienced fraud investigator, but at machine speed and scale.
Detects 5-10% Fraudulent Claims
Industry data shows 5-10% of claims involve fraud, often missed manually, causing major financial losses. Our Agentic AI identifies these hidden patterns that traditional systems miss, catching fraud that costs your organization millions.
Automates High-Risk Screening
Agentic AI analyzes rules, historical patterns, and behavioral anomalies to flag suspicious activities such as duplicate billing, upcoding, unbundling, and phantom services. The system learns from each investigation to improve detection accuracy.
Auto-Triages Claims Efficiently
High-risk claims are automatically routed to Special Investigation Unit (SIU) review with complete documentation. Clean claims are auto-approved, boosting adjudication speed by 30-50% and reducing processing costs.
Delivers 80-90% Detection Accuracy
Industry pilots demonstrate that our AI achieves 80-90% accuracy in fraud detection, greatly outperforming manual fraud detection methods. Continuous learning ensures accuracy improves over time.
Generates $18M+ Savings Annually
A national insurance program saves $18M annually using our AI, with scaling potential to $90M+ across five markets. ROI is typically achieved within 6-9 months of deployment.
Provides Audit-Ready Alerts
Every fraud alert includes clear explanations, evidence trails, and investigation workflows with complete audit trails ensuring governance and regulatory compliance. No black-box decisions — full transparency for regulators and internal teams.
How the AI Investigation Process Works
From claim submission to fraud detection in seconds, not weeks
Claim Ingestion & Analysis
AI ingests claims data in real-time, extracting key information from forms, medical records, billing codes, and provider histories across all submission channels.
Multi-Dimensional Risk Scoring
Agentic AI analyzes multiple fraud indicators: billing patterns, provider behavior, claimant history, medical necessity, and cross-references against known fraud schemes.
Intelligent Triage & Routing
Low-risk claims are auto-approved for payment. High-risk claims are routed to SIU with complete investigation packages, saving investigators hours of prep work.
Continuous Learning & Adaptation
AI learns from investigator feedback, confirmed fraud cases, and emerging fraud patterns to continuously improve detection accuracy and reduce false positives.
Application Across Insurance Verticals
Our FWA detection AI adapts to the unique fraud patterns in each insurance line
Health Insurance
Detect upcoding, unbundling, phantom billing, and medically unnecessary procedures across provider networks.
Auto Insurance
Identify staged accidents, inflated repair costs, phantom passengers, and organized fraud rings.
Property Insurance
Flag inflated valuations, pre-existing damage claims, arson indicators, and contractor fraud.
Workers' Compensation
Detect exaggerated injuries, employment misclassification, and premium fraud schemes.
Medicare & Medicaid
Identify billing fraud, identity theft, DME fraud, and improper payments in government programs.
Life Insurance
Flag application fraud, premium fraud, death certificate forgery, and beneficiary fraud.
Ready to Accelerate Your Transformation?
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