Medical billing and healthcare fraud detection For insurance providers in workers' comp, private health care and automotive lines

RiskShield helps insurance companies focus on suspicious claims, whereas the claims perceived by the software as unsuspicious can directly be settled without wasting time and effort.


Insurance companies around the world today face the problem of how to deal with insurance fraud appropriately -  in particular medical billing fraud. The aim is to present sophisticated claims investigators with a reduced number of highly suspicious claims for manual review. The incoming medical billing claims are analyzed to automatically extract claims that represent potential fraudulent activity or improper medical coding.
RiskShield assesses any fraud risk of individual incoming medical billing claims in real-time in matter of milliseconds and works transparently in the background. Upon receipt of a medical billing claim, the claims management system forwards it to RiskShield. The system uses rule sets and dynamic intelligent profiling to detect fraud patterns. Furthermore, RiskShield scores the medical providers based on the number of suspicious claims in which they are involved so that special attention can be given depending on their ranking.


Andrea Vieten

Andrea Vieten
Presales & Marketing
Tel: +49 (0) 2408 9456 5000

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RiskShield Flyer for Medical Billing
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Features RiskShield

  • Advanced analytics

    Unleash the value of advanced analytics to understand the costs of risks by using predictive modeling, simulations and data visualization tools.

  • Transparent decision logic

    Use easy to understand and user-friendly decision algorithms that can quickly adapt to new modus operandi of fraudsters.

  • Stop known fraud patterns

    Identify improper medical coding such as up-coding, unbundling and duplication of bills and stop payments to avoid fraud losses.

  • Automated link detection

    Identify and link similar shared indicators between people, addresses, phone numbers and objects automatically.

  • Predictive analytics

    Discover new trends and unknown fraud typologies by using advanced intelligent technology and data visualization tools.

  • Business Intelligence

    Dig into detailed information and conduct searches through recent alert activities, identify trends and evaluate statistics using this powerful visualization tool.

  • Flexible integration

    Integrate into the existing claims handling environment without impacting the IT systems with open and highly configurable interfaces.

  • Social Network analysis

    Visually interact with data and analyze alerts and claims to find any social links such as addresses, phone numbers, vehicle identification numbers and more.

  • Case investigation

    Streamline alerts and case investigations with an integration case management tool to manage your information in any form, from any source, all in one single environment.

Medical Billing fraud detection

Medical billing fraud detection

RiskShield assesses the potential risk for medical billing fraud, combining billed items, historical information from medicare provider and performs risk assessment within insurance application data. Finally, working with our customer’s internal management systems, RiskShield can optimize the entire claims process from start to finish allowing clean applications, bills, and claims to flow smoothly and quickly through the system ultimately providing positive customer service. RiskShield helps health care insurance providers by:

  • Determining the risk of fraud for each bill taking into account information from the billed line, previous billed lines, previous claims, patient and provider history.
  • Providing real-time detection of known fraud schemes for example up-coding, unbundling and duplication of bills.
  • Keeping track of high risk health care providers if they move to another line of business or another market.

Business Intelligence

Business Intelligence

Overseeing our core processes, RiskShield’s Business Intelligence dashboard can be configured to analyze active alerts & key performance indicators to uncover hidden patterns or unusual behavior ultimately maximizing our customer’s fraud detection performance and minimizing the number of false positives. Canned and ad-hoc report management can then provide reports as desired by our customers.

RiskShield Business Intelligence provides fraud managers a powerful tool to dig into detailed information and conduct searches through recent customer activities, identify trends and evaluate statistics.

  • Reduce the risk of fraud through advanced analytic capabilities and greater visibility.
  • Discover new valuable insights of fraudulent behavior that can lead to a more proactive and predictive approach of fraud prevention.
  • Reduce false positives by monitoring the performance of anti fraud scenarios and alert settings.


Predictive analytics

Predictive analytics

With a predictive approach, RiskShield incorporates time proven methods such as fuzzy logic, pattern recognition, business rules, and the use of both internal and external data sources to score claims quickly and effectively resulting in valuable insights of fraudulent behavior. Sounds complex to maintain, but RiskShield’s rules can actually be created, tested, verified, and deployed in real-time by fraud specialists of insurance companies themselves without any vendor support, IT support, or system downtime. With RiskShield Predictive Analytics customers can:

  • Discover new trends and unknown fraud typologies by using data visualization tools and advanced intelligence.
  • Reduce fraud losses by detecting known patterns faster with a real-time monitoring and prevention decision engine.
  • Analyze, simulate and test to optimize fraud detection accuracy and lowering false positives.
  • Stay in control with ongoing fraud prevention using transparent and user friendly decision technology.



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