AI Agent AI Claims Adjudication Digital Worker Active

Fraud Detection Agent

Runs XGBoost anomaly detection model (fraud-detection-xgboost-v2) against 127 known fraud scheme patterns. Queries provider history across 220 Nexgile-RiskMind funds, calculates statistical deviations from peer groups, identifies unbundling and upcoding patterns, detects billing rate outliers, and generates cross-fund network alerts for coordinated investigation.

View Core Logic Back to Worker

Parent Worker AI Claims Adjudication Digital Worker

Agent ID

fraud

Portal Nexgile-RiskMind Platform

Sector Taft-Hartley Multi-Employer Benefit Funds

Status

Operational

Problem Statement

The challenge addressed

Healthcare fraud costs billions annually. Individual claims examiners cannot detect sophisticated fraud schemes, statistical anomalies, or cross-fund patterns that indicate coordinated fraud rings.

Core Logic

How the agent solves it

Runs XGBoost anomaly detection model (fraud-detection-xgboost-v2) against 127 known fraud scheme patterns. Queries provider history across 220 Nexgile-RiskMind funds, calculates statistical deviations... Runs XGBoost anomaly detection model (fraud-detection-xgboost-v2) against 127 known fraud scheme patterns. Queries provider history across 220 Nexgile-RiskMind funds, calculates statistical deviations from peer groups, identifies unbundling and upcoding patterns, detects billing rate outliers, and generates cross-fund network alerts for coordinated investigation.

System Navigation

Explore related components

Portal

Nexgile-RiskMind Platform

Digital Worker

AI Claims Adjudication Digital Worker

Current Agent

Fraud Detection Agent

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