Workers' comp claims automation, with fraud investigation built in
Workers' comp fraud costs insurers an estimated $34 billion annually. Fabricated injuries, exaggerated disability, and provider collusion require investigation depth most carriers can't staff. Hesper AI runs a full investigation on every claim in minutes.
In short
Hesper AI's agents take a workers' compensation claim from first report, extract the injury facts, test compensability against the policy and the jurisdiction, summarize the medical records, and recommend a reserve. Routine claims move straight through. Claims with red flags get an investigation-grade workup, and every file is screened for subrogation before it closes.
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Common workers' comp fraud schemes
Workers' comp fraud spans individual claimants, provider networks, and employer premium avoidance. Hesper investigates every flagged claim across all four schemes simultaneously.
Fabricated injuries
Claimants report workplace injuries that never occurred. Hesper AI cross-references medical records with workplace incident reports, analyzes document timelines for inconsistencies, and detects altered or fabricated medical documentation at the pixel level.
Exaggerated disability
Legitimate injuries with exaggerated severity or extended recovery periods. Hesper AI analyzes treatment patterns against expected recovery timelines, cross-references provider billing against diagnosis norms, and flags treatment that exceeds standard protocols.
Working while claiming
Claimants collecting disability benefits while employed elsewhere. Hesper AI conducts OSINT analysis including social media monitoring, employment database checks, and business registration searches to identify income sources inconsistent with claimed disability status.
Employer premium fraud
Employers misclassifying workers or underreporting payroll to reduce premiums. Hesper AI analyzes payroll documents for alterations, cross-references employee classifications against job descriptions, and detects discrepancies between reported and actual workforce data.
Manual workflow vs. Hesper
Every phase compresses. The cumulative effect is the difference between a two-week cycle and a decision in minutes.
How Hesper AI investigates a workers' comp claim
Every workers' comp claim runs through a structured pipeline. Phases run in parallel where dependencies allow.
Medical record ingest and forensics
All medical records, treatment notes, diagnostic imaging reports, and billing codes are ingested and analyzed. Hesper checks for document authenticity, altered dates, fabricated records, and CPT upcoding against injury severity.
Treatment timeline reconstruction
Treatment patterns are cross-referenced with the reported injury mechanism and recovery norms. Claims where treatment dates predate the injury, exceed standard protocols, or conflict with diagnostic imaging are surfaced with cited evidence.
OSINT and claimant activity scan
Public social media, professional networks, and business registrations are scanned for evidence inconsistent with claimed disability status. Findings are captured with source URLs, timestamps, and archived snapshots.
Provider and network analysis
Treating physicians, attorneys, and therapy providers are mapped against prior claims. Hesper surfaces patterns of shared providers across multiple suspicious claims and flags network clusters consistent with organized fraud.
Investigation report and recommendation
A complete investigation report is generated with medical findings, OSINT evidence with preserved links, network diagrams, and a denial or settlement recommendation. Report is SIU-ready and defensible in administrative hearings.
Annual US workers' compensation fraud
2022 estimate, supersedes the decades-old $7B figure
Source: Coalition Against Insurance FraudNonfatal workplace injuries and illnesses reported by private employers in 2024
Down 3.1% from 2023
Source: US Bureau of Labor StatisticsHesper AI investigation time per claim
Hesper internal benchmark. Vs. 14+ days manually
Fraud signals analyzed per document
Hesper internal benchmark. Medical + OSINT + financial
Workers' compensation claims automation, answered
How does AI claims automation work for a workers' compensation claim?
The agents pick up the first report of injury, pull the loss facts out of forms, emails, and attachments, test compensability against the policy and the jurisdiction's rules, summarize the medical file, and recommend a reserve. Straightforward claims resolve without a manual touch. Compensability and reserve authority stay with the adjuster.
Can AI review workers' comp medical records and treatment timelines?
Yes. The agents read the full medical file, reconstruct the treatment timeline against the reported date of injury, flag billing codes that do not match the documented diagnosis, and benchmark utilization against comparable claims. Every flag cites the page it came from, so a nurse reviewer or examiner can check it in seconds.
How does Hesper detect an exaggerated or fabricated workplace injury?
Fraud detection is built in rather than licensed from another vendor. The agents cross-reference recorded statements against the medical record and the incident report, run OSINT and public-record checks, and map providers, clinics, and attorneys that recur across unrelated claims. The finding, the referral, and the denial decision stay with your team.
Can Hesper help a TPA carrying heavy caseloads?
That is the core case for it. Manual investigation runs 14+ days per file and one investigator typically carries 200+ open cases, which is why roughly three quarters of flagged claims never get a full workup. Hesper does the legwork on every file, so the examiner reviews an evidence-backed claim instead of building the record by hand.
Does Hesper handle workers' comp subrogation and third-party recovery?
Every claim is screened for subrogation and salvage before closure, including third-party liability on a workplace injury. Where recovery is viable the agents draft the demand and assemble the evidence behind it. Your team decides whether to pursue or waive.
Is claim data secure, and is Hesper audited?
Hesper is SOC 2 and HIPAA compliant and GDPR-ready, with data encrypted in transit and at rest. Claim file data and output are retained for the subscription term unless you instruct otherwise, and are never used to train models. Every agent action is logged with its sources, reasoning, and timestamps for regulators and reinsurers.
Go deeper on workers' comp fraud
Research, technical deep-dives, and playbooks from the Hesper AI team.
See Hesper investigate your workers' comp claims
We'll run a sample investigation on your real flagged claims and show you the evidence package and report it produces.