Health insurance claims: document extraction and fraud signals

Solution blueprint. This describes how BigAI delivers this type of project, using our products and methods. It is not a specific client engagement.

The challenge

Each health claim brings many pages of bills and reports in different formats. Manual reading is slow, and inflated or duplicate billing is hard to catch.

Our approach

1. Extract line items, diagnoses and procedures from documents with confidence scores.
2. Check entries against policy terms, tariffs and medical consistency.
3. Score fraud and abuse risk using patterns across claims and providers.
4. Show investigators the reasons behind each flag.

The solution

• Document extraction pipeline
• Policy and tariff checks
• Explained fraud scores
• Investigator queue

What we measure

• Extraction accuracy per field
• Processing time per claim
• Investigator hit rate on flagged claims