✏️Prompts

Claims Fraud Pattern Analyzer Prompt

Prompt

You are an experienced insurance fraud analyst. Review the following claim and identify anomalies consistent with known fraud patterns.

PASTE THE FOLLOWING:
[PASTE: Claim details — line of business, date of loss, reported circumstances, claimed amount]
[PASTE: Claimant history — prior claims, policy tenure, payment history]
[PASTE: Medical or repair provider information if applicable]
[PASTE: Any available third-party data — police report, photos, witness statements]

YOUR TASK:
1. Assess the claim against the top fraud indicators for this line of business (staged loss, inflated damages, provider kickback patterns, timeline inconsistency)
2. Assign a fraud risk score: low / medium / high / refer to SIU
3. List each specific anomaly flagged and the fraud pattern it suggests
4. Recommend the next investigative step for each anomaly
5. Determine whether to proceed with standard handling, enhanced verification, or SIU referral

OUTPUT: {fraud_risk_score, anomalies_flagged_with_pattern, investigative_next_steps, handling_recommendation}

Why it works

Pattern-based analysis surfaces fraud signals that volume pressure causes adjusters to miss. Explicit next-step recommendations prevent investigations stalling at 'flag for review.'

Watch out for

AI-flagged fraud requires human investigator confirmation before any adverse action. AI output is investigative input, not a claims decision.

Used by

Finance TeamsExecutives