Investigation

Claims Triage

Claims triage is the process of screening incoming insurance claims to assess risk level, identify red flags, and prioritize which claims require investigation. It is the first step in the fraud detection pipeline - determining which of the thousands of daily claims warrant deeper review.

In this article

How claims triage works What triage systems look for The gap between triage and investigation Key points How Hesper AI helps FAQ

How claims triage works

When a claim is filed, it passes through an initial screening process. This can be rule-based (checking against known fraud indicators), model-based (predictive scoring using historical data), or a combination. Claims are typically scored on a risk scale and routed accordingly: low-risk claims proceed to normal adjustment, medium-risk claims get flagged for additional review, and high-risk claims are referred directly to the SIU.

What triage systems look for

Triage systems evaluate dozens of signals: claim timing (filed late Friday before a holiday), claimant history (prior claims frequency), provider patterns (same medical provider across multiple claims), document anomalies (metadata inconsistencies), financial indicators (claim amount just below audit thresholds), and behavioral signals (rushed or rehearsed statements). The best triage systems combine multiple signal types rather than relying on any single indicator.

The gap between triage and investigation

Modern triage and detection tools (FRISS, Shift Technology, Verisk) are effective at flagging suspicious claims. The problem is what happens next. Flagging a claim is not the same as investigating it. Most carriers flag 8-12% of claims as suspicious, but their SIU can only investigate a fraction. The claims that are flagged but never investigated represent the largest source of preventable fraud loss.

Key points

First step in the fraud detection pipeline
Uses rules, predictive models, or both to score claim risk
Evaluates timing, history, provider patterns, document anomalies, and behavioral signals
Modern tools flag 8-12% of claims - but most are never investigated
The gap between flagging and investigation is where fraud losses occur

How Hesper AI helps

Hesper AI closes the gap between triage and investigation. When your detection tools flag a claim, Hesper automatically deploys an AI investigation agent - ensuring every flagged claim gets a thorough investigation, not just the ones your SIU has bandwidth for.

Related glossary terms

Special Investigations Unit (SIU)Insurance Fraud Red Flags First Notice of Loss (FNOL)

Frequently asked questions

Claims triage is the screening and risk-scoring step that decides how a claim should be handled. Claims adjustment is the process of evaluating and settling the claim. Triage happens first and determines whether a claim goes through normal adjustment or gets flagged for investigation.

Common triage and detection tools include FRISS (risk scoring), Shift Technology (AI-based detection), Verisk (data analytics and rule-based detection), and carrier-built rule engines. These tools score claims against fraud indicators and historical patterns to prioritize investigation.

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