AI Fraud Triage Agent with OneShield: The AI Layer That Sits Above Your Core System

The Problem: OneShield Doesn't Do This

OneShield is excellent at what it's designed for: Policy administration, Claims management, Billing, Rating. It's your system of record for specialty lines platform, and replacing it is not on the table for any rational CTO.

Claims fraud costs the US insurance industry $80B annually. SIU teams cannot review every claim — manual referral rates of 1-3% mean the majority of fraudulent claims are paid without investigation. Document-level fraud signals (staged accident indicators, provider billing anomalies, claim inflation patterns) are invisible without AI analysis.

This isn't a failure of OneShield — it's a capability gap that falls outside its design scope. The solution isn't to rip and replace OneShield. It's to add an intelligence layer on top that handles what OneShield doesn't.

The Regure Approach: Intelligent Orchestration Layer

Regure connects to OneShield via standard REST API integration without requiring customization or modification of your OneShield configuration.

Regure analyzes every claim document against a fraud signal library: medical provider billing history, accident scenario consistency, claimant claim frequency, contractor pricing benchmarks, and document metadata anomalies. Claims exceeding configurable risk thresholds are automatically routed to SIU with an evidence package.

Every action taken by Regure is logged and visible in both Regure's audit trail and pushed back to OneShield records — so your team works in the system they know, with Regure handling the AI processing invisibly in the background.

Key Documents Processed for Fraud Triage

For AI Fraud Triage Agent, Regure processes the following document types that OneShield holds references to but doesn't analyze:

• CMS-1500
• UB-04
• Police report
• Contractor invoice
• FNOL
• IME report

These documents arrive as PDFs, images, and structured data feeds. Regure's AI extracts the signals relevant to fraud triage, enriches the OneShield record with structured findings, and triggers appropriate workflows — all without manual intervention.

Implementation: Non-Invasive, Rapid Deploy

Regure is designed specifically to avoid the "rip and replace" problem. Implementation alongside OneShield takes weeks, not months:

1. Connect: Regure authenticates with OneShield via API using read/write credentials limited to the required data scopes. No OneShield customization required.
2. Configure: Define which OneShield workflows trigger Regure processing and which Regure outputs write back to OneShield records.
3. Train: Provide Regure with your specific document examples — your carrier's forms, your adjusters' workflows — and the AI calibrates to your operation.
4. Go live: Regure processes documents in parallel with existing workflows. Adjusters and underwriters see enriched data in OneShield without changing their workflow.

ROI for Fraud Triage on OneShield

Automated fraud triage typically increases SIU referral quality (confirmed fraud rate) by 40-60% while expanding overall referral volume, with ROI consistently exceeding 10:1 on investigation costs vs. losses prevented.

The ROI case for adding Regure's fraud triage capability to OneShield is straightforward: you're applying AI intelligence to document workflows that OneShield already handles transactionally, with no displacement cost, no retraining cost, and no integration risk beyond the initial API connection.

Other AI Use Cases for OneShield

Fraud Triage is one of five AI capability layers Regure adds to OneShield. The full suite:

• AI Subrogation Detection Agent — Automatically identify subrogation opportunities from claim documents at FNOL and throughout adjudication
• AI Fraud Triage Agent ← Current page — Real-time fraud signal detection in claims documents, flagging suspicious patterns for SIU referral
• Compliance Automation — Automated regulatory evidence generation integrated with core system workflows
• Renewal Intelligence — AI-powered renewal prediction and portfolio analysis from core system and document data
• Claims Leakage Prevention — Systematic identification of overpayment, coverage gaps, and process failures driving claims leakage

Ready to add fraud triage to your OneShield operation? Book a demo — bring your OneShield setup details and we'll show you exactly how the integration works. Or see the OneShield integration overview.