Claims Fraud Referral Review Agent

Fraud scores flag many claims for the wrong reasons, so honest customers get delayed and investigators waste time. This agent reviews claims flagged by the fraud score before referral. For each one it pulls the claim file and policy history and checks each red flag that drove the score, such as a recent policy start, prior claims, repeat providers or inconsistent dates. It verifies each flag is real, since data errors often cause false flags, and removes those. Claims with two or more confirmed flags are recommended for referral with a written reason. Adjusters or the special investigations unit decide. Each month it checks investigator outcomes against the flags used and proposes a review of flags with a low hit rate. Edge case: a policy looked new because it was rewritten with a new number, so the agent removes that flag.