Reimagine fraud detection: A proactive, continuous, and scalable approach
Fraud, waste, and abuse (FWA) cost the U.S. healthcare system billions of dollars each year. Beyond the financial burden, it erodes trust, increases costs for payers, and diverts resources away from patient care.
For decades, the struggle against FWA has looked much the same: manual, retrospective, and resource constrained. Investigations often begin after payments are made, with only a small subset of claims selected for review. This approach is slow, reactive, and limited by the size of investigative teams.
Agentic AI offers a different vision for fraud detection.
Moving beyond anomaly detection
Traditional AI models and analytics tools have helped healthcare organizations spot outliers, but agentic AI goes further. These agents can be deployed across the entire FWA workflow, making detection and resolution proactive, continuous, and scalable.
Agentic AI can:
- Continuously analyze all claims data, not just a sample.
- Correlate information from multiple sources, both internal and external, to build contextual understanding.
- Learn and adapt over time, staying ahead of evolving fraud tactics.
- Flag and prioritize cases, enabling faster intervention before financial leakage occurs.
Rather than just discovering anomalies, agents can orchestrate actions, escalating the most important cases directly to investigators. Payment integrity professionals can resolve cases faster, significantly reducing financial losses.
Elevating the human role
It is important to note that AI-driven systems do not replace the human investigator. Instead, this technology reshapes the role of this position. Instead of spending countless hours combing through data, investigators start from insights and analyses surfaced by AI. This allows them to concentrate on higher-yield, strategic activities: evaluating complex cases, applying judgment to ambiguous situations, and shaping enforcement strategies.
Why it matters
Healthcare organizations face a dual challenge: FWA continues to grow in scale and sophistication, while investigative resources remain finite. Traditional workflows are struggling to keep pace.
Advanced AI technologies offers a new way, not just incremental improvement, but a structural change in how organizations approach risk and compliance. By scaling detection, accelerating resolution, and continuously adapting to new fraud patterns, agentic AI expands the reach and effectiveness of FWA efforts in ways that were previously not possible.
Moving forward with agentic AI
As the industry moves from reactive enforcement to proactive intelligence, agentic AI stands to become a cornerstone of how the healthcare system protects itself from fraud, waste, and abuse in the years ahead.
This new approach to FWA calls for specialized expertise. Partnering with an experienced third-party provider can accelerate adoption, reduce risk, and ensure that advanced capabilities are deployed effectively at scale.
EXL has been recognized as a Leader and Star Performer in Everest Group’s Payment Integrity Solutions PEAK Matrix® Assessment 2025, in part because of its ability to integrate generative AI, natural language processing, and machine learning into proactive fraud detection workflows.
Let’s work together to transform your healthcare payment integrity operations. Learn more about EXL’s healthcare payment integrity solutions.