Claims Fraud Detection and Subrogation Prioritization
AI-assisted claims workflow for insurers that detects potentially fraudulent or high-risk claims, supports end-to-end claims handling and triage, and prioritizes subrogation and forensic review to improve recovery, speed, and accuracy.
The Problem
“Claims fraud detection and subrogation prioritization for insurance claims operations”
Organizations face these key challenges:
High volume of claims with limited adjuster and SIU capacity
Fraud indicators spread across notes, documents, images, and historical claims
Legacy claims systems create fragmented workflows and duplicate data entry
Static rules generate too many false positives or miss novel fraud patterns
Impact When Solved
The Shift
Human Does
- •Review FNOL details, reports, bills, photos, and adjuster notes manually
- •Apply static fraud, severity, and subrogation rules to triage claims
- •Escalate suspicious, complex, or recoverable claims to SIU or recovery specialists
- •Investigate liability, request missing evidence, and decide claim handling next steps
Automation
Human Does
- •Approve SIU referral, forensic review, subrogation pursuit, and other material claim decisions
- •Review AI-ranked high-risk or high-recovery claims and validate recommended actions
- •Handle exceptions, novel scenarios, and disputed claims requiring judgment
AI Handles
- •Continuously score claims for fraud risk, severity, and subrogation potential as new evidence arrives
- •Extract facts, entities, timelines, and liability signals from claim documents, notes, and images
- •Detect anomalies, contradictions, and related-claim patterns to prioritize investigation
- •Generate case summaries, missing-evidence prompts, and next-best-action routing recommendations
Operating Intelligence
How Claims Fraud Detection and Subrogation Prioritization runs once it is live
AI runs the first three steps autonomously.
Humans own every decision.
The system gets smarter each cycle.
Who is in control at each step
Each column marks the operating owner for that step. AI-led actions sit above the divider, human decisions and feedback loops sit below it.
Step 1
Assemble Context
Step 2
Analyze
Step 3
Recommend
Step 4
Human Decision
Step 5
Execute
Step 6
Feedback
AI lead
Autonomous execution
Human lead
Approval, override, feedback
AI handles assembly, analysis, and execution. The human gate sits at the decision point. Every cycle refines future recommendations.
The Loop
6 steps
Assemble Context
Combine the relevant records, signals, and constraints.
Analyze
Evaluate options, risk, and likely outcomes.
Recommend
Present a ranked recommendation with supporting rationale.
Human Decision
A human accepts, edits, or rejects the recommendation.
Authority gates · 1
The system must not make a final SIU referral, forensic review decision, or subrogation pursuit decision without review by the responsible claims professional. [S1]
Why this step is human
The decision carries real-world consequences that require professional judgment and accountability.
Execute
Carry out the approved action in the operating workflow.
Feedback
Outcome data improves future recommendations.
1 operating angles mapped
Operational Depth
Technologies
Technologies commonly used in Claims Fraud Detection and Subrogation Prioritization implementations:
Key Players
Companies actively working on Claims Fraud Detection and Subrogation Prioritization solutions:
+10 more companies(sign up to see all)Real-World Use Cases
AI-driven end-to-end claims transformation for personal lines insurer
The insurer used AI and automation to read incoming claims, apply rules about damage and compensation, help staff make better decisions, and move claims through faster with less manual work.
AI-driven claims handling and fraud detection
Insurers use AI to review claims, flag suspicious ones, and help decide which claims need more human attention.
AI-assisted loss triage, subrogation targeting, and forensic analysis
FM is exploring AI to spot which claims need attention first, identify where money can be recovered from third parties, and support forensic accounting and investigation work.
AI-powered claims subrogation scoring and prioritization in Guidewire ClaimCenter via CCC Safekeep
The app helps insurers find which claims might get money back from another party, ranks the best opportunities, and sends the right evidence faster so adjusters do less manual work.