Use Cases / Workers' Comp

Workers' comp investigation, fully automated

Workers' comp fraud costs insurers $7.2 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 2-4 hours.

Investigation in progress

WC-2026-034812

Back injury · $88,400 exposure · light duty refused

Running

12m elapsed

Progress20%

Investigation phases

✓

Medical record forensics9m

Treatment timeline analysis

OSINT & social media scan

Employment & income verification

Provider network pattern analysis

Evidence gathered2 items

ClaimBack injury reported 2026-01-18 - light duty denied

MedicalTreatment codes show CPT upcoding vs injury severity⚠

Risk score

Low signal

28

/ 100

[01] Fraud patterns

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.

Est. loss impact

~$2B

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.

How Hesper detects it

Medical record forensicsIncident report matchTimeline analysisDocument authenticity

Est. loss impact

~$3B

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.

How Hesper detects it

Recovery timeline analysisBilling pattern detectionTreatment norm comparisonDiagnosis alignment

Est. loss impact

~$1B

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.

How Hesper detects it

Social media analysisEmployment verificationBusiness registration searchIncome inconsistency

Est. loss impact

~$1.2B

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.

How Hesper detects it

Payroll document analysisClassification verificationWorkforce data validationAudit trail

[02] Timeline compression

Manual workflow vs. Hesper

Every phase compresses. The cumulative effect is the difference between a two-week cycle and a same-day decision.

Investigation phase

Manual workflow

Hesper AI

Medical record review

Peer review vendor, 5-7 days

Automated, 9 min

Treatment timeline analysis

Investigator reconstruction, 1 day

AI analysis, 6 min

OSINT & social media scan

Manual investigation, 2-4 days

Automated scan, 8 min

Provider network mapping

Analyst diagramming, 1-2 days

Auto-graph, 11 min

Report assembly

Investigator write-up, 6-10 hrs

Auto-generated, 0 min

Total time

14-21 days

2-4 hours

[03] Investigation flow

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

~9 min

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.

Document authenticityCPT code validationDate forensicsSignature analysis

Treatment timeline reconstruction

~6 min

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.

Injury-treatment matchRecovery protocol checkPrior-care detectionProvider benchmarking

OSINT and claimant activity scan

~8 min

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.

Social media scanLinkedIn analysisBusiness registrationArchived evidence

Provider and network analysis

~11 min

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.

Provider flaggingAttorney networkCluster detectionISO ClaimSearch match

Investigation report and recommendation

~13 min

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.

Medical findingsOSINT citationsNetwork diagramsHearing-ready output

[04] By the numbers

$0B

Annual workers' comp fraud in the US

Per Coalition Against Insurance Fraud

Of workers' comp claims involve some fraud signal

Across all claim severities

2-4h

Hesper AI investigation time per claim

Vs. 14+ days manually

Fraud signals analyzed per document

Medical + OSINT + financial