Healthcare and Medical Billing

insurance claim fraud detectionInsurance companies around the world today face the problem of how to deal with insurance fraud appropriately, in particular medical billing fraud. The aim is to present sophisticated claims investigators a reduced number of highly suspicious claims for manual review. The incoming medical billing claims are analyzed to automatically extract claims that represent potential fraudulent activity.


RiskShield assesses any fraud risk of individual incoming medical billing claims in real-time in matter of milliseconds and works transparently in the background. Upon receipt of a medical billing claim, the claims management system forwards it to RiskShield. The system uses rule sets to detect more than twenty known fraud patterns. Furthermore, RiskShield scores the medical providers based on the number of suspicious claims, in which they are involved so that special attention can be given depending on their ranking.


Such an automated software solution helps the investigators of the insurance company focus on the suspicious claims, whereas the claims perceived by the software as unsuspicious can directly be settled without losing further time.


Riskshield allows us to more effectively allocate our investigative resources to those cases with the most fraud potential.

Director of Claims Security and Special Investigation Unit at GEICO


In 2011, auto insurers in the United States paid out more than $64 billion in bodily injury liability claims, versus about $40 billion for physical damage to the vehicles.  The consensus estimate is that approximately 15% of the bodily injury claims are fraudulent in some way. The savings achieved by utilizing RiskShield to automatically detect these fraudulent are substantial and have been proven in real-live application in the U.S.


The issue is not unique to the United States. A common type of fraud in many countries is in the form of unsubstantiated “whiplash” claims, i.e. claims for neck sprains and strains in low impact collisions. European countries have a growing number of “whiplash” related claims in motor vehicle accidents. Evidence from the Association of British Insurers demonstrates that 78% of personal injury claims in the UK resulting from road accidents are for whiplash. Numbers from some other European countries are not far behind.



Customer References

Some of our key references in healthcare and medical billing fraud detection

GEICO Zurich Insurance Group Announced Soon


For more information about how RiskShield can help fighting medical billing fraud please contact us for a live demo or presentation.