How AI claims automation works, stage by stage
Hesper AI is an AI claims resolution platform for P&C carriers, TPAs and MGAs. Its agents take a claim at first notice, extract the file, score and route it, verify coverage, run a full investigation when something looks wrong, and screen it for recovery before it closes. Here is what happens at each stage, and what stays with your team.
What happens on a suspicious claim?
Every AI investigation agent runs the same structured workflow your best human investigators follow - just faster, more consistent, and with zero case backlog.
01 · Intake & Context
Claim intake & triage
The agent ingests all available claim data - loss details, policy information, adjuster notes, photos - and assigns an initial risk score based on known fraud indicators.
Policy coverage verification
Cross-references the claimed loss against actual policy terms, coverage limits, endorsements, and exclusions. Flags coverage gaps and suspicious timing around policy changes.
Claimant history & prior claims analysis
Searches ISO ClaimSearch, NICB, and internal databases for prior claims by the same claimant, address, or vehicle. Identifies frequency patterns and repeat-offender signals.
02 · Evidence Gathering
Statement collection & cross-referencing
Analyzes recorded statements and written narratives from all parties. Detects contradictions, timeline inconsistencies, and rehearsed language patterns across multiple accounts.
Document authenticity verification
Runs forensic analysis on submitted documents - repair estimates, medical bills, receipts. Detects pixel manipulation, font inconsistencies, metadata tampering, and AI-generated fakes.
Medical record analysis
Reviews medical records for billing anomalies, pre-existing conditions presented as new injuries, excessive treatment patterns, and inconsistencies between claimed injuries and documented findings.
Social media & OSINT investigation
Scans public social media profiles, public records, and open-source intelligence for evidence that contradicts the claim - vacation photos during a disability claim, vehicle sightings after a total loss.
03 · Analysis
Witness identification
Identifies potential witnesses from police reports, accident scenes, and public records. Cross-references witness information against known fraud ring databases and prior claim involvement.
Timeline reconstruction
Builds a complete timeline of events from all available data sources - call logs, claim submissions, medical visits, repair shop interactions. Highlights gaps and impossible sequences.
Financial analysis
Evaluates the financial context of the claim - inflated repair estimates, excessive medical billing, unusual vendor pricing patterns, and cost outliers compared to regional benchmarks.
Subrogation detection
Identifies third-party liability and recovery opportunities. Flags claims where another party may be responsible, potentially offsetting payout and reducing net loss.
04 · Output
Regulatory compliance checks
Validates that the investigation meets state-specific regulatory requirements, fair claims handling guidelines, and documentation standards before report assembly.
Evidence package assembly
Compiles all gathered evidence into an organized, indexed package - documents, screenshots, database results, timeline visualizations - ready for SIU review or legal proceedings.
Investigation report with recommendations
Generates a structured investigation report with findings, risk assessment, supporting evidence, and clear recommendations - approve, deny, refer to SIU, or escalate to law enforcement.
Surveillance coordination triggers
When field surveillance is warranted, the agent generates geo-fenced surveillance plans with optimal timing windows based on claimant behavior patterns and activity analysis.
What comes back at the end?
Other tools give you a number. Hesper AI gives you a complete investigation report your SIU team can act on immediately - with evidence, justification, and a clear recommendation.
Can we see it on one of our own claims?
Walk through a live investigation with your own claims data. 30 minutes. No commitment.