botminds.aiRequest a demo
WorkflowSpecial Investigations

Provider Fraud Review

Provider & Network Fraud Review

Every bill from a flagged provider read against its records and peers, so upcoding and phantom visits surface early.

Book a demoMore in Special Investigations
Film coming soonSee it working, liveWe’ll walk you through Provider Fraud Review on your own documents.
Book a demo
WorkflowDocuments in; a checked, signed result out.
5specialist agents
5kinds of input
Soonfilm in production
The problem

Why it matters

Upcoding, unbundling, phantom visits and inflated hospital bills hide across thousands of claims; reviewers can only sample a provider’s files by hand.

What it does

How the solution handles it

Agents read every bill from a flagged provider, match it to the clinical record, compare codes, volumes and charges with peers, and map owners and referral links. They draft a cited provider brief; the SIU investigator decides on audit, network action or referral.

How it works

How a provider review moves

Five agents read every bill, match it to the clinical record, compare it with peers, map owners and draft the brief; an SIU investigator decides what follows.

What comes in
Bills + records4 sources · claims, bills, clinical notes, licences
Agents at work
Bill readerCMS-1500 · UB-04
Then
Record matcherbill vs chart
Pattern analystcodes, volumes, peers
Network mapperowners, referrals
Then
Case summarizercited provider brief
A person decides
SIU investigatordecides what follows
What comes out
Cited provider brief
Peer outliers
Network map
In and out

What it reads, and what it hands back.

What goes in

  • CMS-1500 and UB-04 claims
  • Hospital bills and discharge summaries
  • Clinical notes and treatment records
  • Provider ownership and licence records
  • Body-shop estimates and invoices

What comes out

  • Cited provider brief
  • Billing pattern findings vs peers
  • Ownership and referral map
  • Audit or referral recommendation

Who uses it

SISIU investigatorMRMedical reviewerPNProvider network managerTFTPA fraud control unit
What it changes

The difference, in numbers.

Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.

target
5days
to a cited provider brief, from flag to review-ready
By hand4–6 weeks
With agents≈ 5 days
target
100%
of a flagged provider’s claims reviewed, not a sample
every claim, not a sample
typical
3–10%
of health spending lost to fraud, by industry and law-enforcement estimates

“Target” = design goal, measured in the live solution · “Typical” = NHCAA (3%, conservative) and FBI (up to 10%) estimates; in India ≈ ₹8,000–10,000 crore a year (BCG, 2025) · agents = the live solution’s configuration

Built on the engine

5 specialist agents. One person decides.

Bill readerUS claim forms and hospital bills
Record matchereach billed line to its clinical note
Pattern analystoutliers against peer providers
Network mapperowners, staff and referral links
Case summarizerone cited brief per provider
SIU investigatordecides what follows
Special Investigations

More in this division.

All 6 solutions →
Fraud Referral Triage

Every fraud referral scored and explained in minutes, so investigators open the files that matter first.

Document Tampering

Every invoice, photo and receipt checked for edits and reuse before money moves, each finding marked on the page.

Investigation File

Every SIU case becomes one cited file — timeline, statements, findings — ready for counsel or the fraud bureau.

Build this
for your team.

We’ll show Provider Fraud Review running on your own documents.

Book a demoBrowse solutions