Medical Document Fraud Detection for Insurance Claims
Medical claim attachments—invoices, prescriptions, treatment summaries, lab reports, and provider documents—can be edited, duplicated, or synthetically generated. Frodau applies document-type classification, medical identifier plausibility checks, arithmetic consistency, and forensic detectors. This is operational document review, not clinical diagnosis.
Key takeaways
- Document-type classification reduces wrong-file payouts (e.g., non-medical uploads).
- Medical identifier validation flags implausible provider or drug identifiers.
- Line-item analysis marks covered vs. excluded items where policy rules apply.
- No clinical claims—only document integrity and consistency.
Document types in scope
- Medical invoices and pharmacy receipts
- Prescriptions and dispensing records
- Treatment summaries and clinic documentation
- Lab reports and provider letters
Checks Frodau applies
- Provider and medical identifier plausibility
- Semantic consistency of fields and labels
- Arithmetic consistency of totals and copays
- Manipulation indicators from metadata and ELA
- Duplicate detection across the organization's corpus
FAQ
- Does Frodau validate clinical accuracy?
- No. Frodau analyzes document integrity, duplication, type, payable lines, and fraud-oriented signals—it does not diagnose patients or judge medical necessity.