Catch suspicious provisions and claims before payment.
Abuse in health and general insurance rarely sits in one claim amount. It sits in behavior across policyholders, policies, providers, pharmacies, physicians, and procedure codes. True Guard Vision turns those signals into cases — with the relationship network attached.
Where abuse hides in the network
Configured with your provision, claim, and provider events — no customer names, just your patterns.
Repeat & Excess Procedures
Repeated procedure codes, frequency far above peer norms, and billing that diverges from the member's own history.
Behavior vs. own historyProvider Concentration
Members cycling through unusual provider sets, sudden provider switches, and volume concentrated at one facility.
Provider velocity signalsRelationship Rings
Shared physicians, pharmacies, and facilities across members and claims — the ring behind individually clean claims.
Graph ring detectionPre-Payment Screening
Provisions and claims evaluated in the flow, returning warnings and actions without interrupting the core decision process.
In-flow evaluationWatchlists That Learn
Suspicious and trusted providers, policies, procedure codes, and accounts maintained as live lists inside rules.
Analyst-owned listsCase-Ready Context
Alarms grouped by member or provider with events, rules, profiles, and notes in one investigation workspace.
Faster, calmer reviewFrom event to action in one flow
Provision, claim, invoice, and portal events arrive over API — and return a decision your systems can use.
Dynamic behavior profiles
Counts, totals, averages, and frequency windows per member and per provider — so fixed thresholds sit beside deviation from own history.
Graph intelligence
First-time links, short-window intensity, shared neighbors, multi-hop paths, and proximity to past abuse cases feed decisions and review.
Governance included
Role-based access, project separation, audit trails, and performance views keep the abuse operation measurable and controlled.
POC checklist
- Provision and claim events with member, provider, procedure
- Provider, pharmacy, physician, and invoice attributes
- Suspicious and trusted lists your team keeps
- On-premise or private-cloud deployment as required