Smart Applications AI app to reduce claims fraud, up quality

Smart Leadership team during the official launch of Smart Detect Ai at Safari Park Hotel. [Esther Dianah, Standard]

The recently launched claims intelligence platform, Smart Detect AI by Smart Applications International Ltd, will help transform healthcare claims  management by tackling fraud, waste and abuse.

This will reduce inefficiencies and strengthen financial integrity across healthcare systems in Africa. Healthcare claims are at the core of every patient interaction, and as they continue to grow, hidden risks such as fraud, waste, and abuse remain a significant challenge.

These losses are often driven by complex fraud schemes  hidden within normal-looking claims, making them difficult to detect using traditional rule-based systems.

A large proportion of claim rejections are preventable, often arising from issues such as incomplete documentation, incorrect coding, or inconsistencies that are only identified after submission - affecting both revenue predictability and operational efficiency.

Smart Detect AI addresses these challenges by introducing a new layer of intelligence into the claims process. Using machine learning, behavioural analytics, and clinical logic, the solution analyses claims both before and after submission to identify risks, improve accuracy, and enhance decision-making.

For insurers, Smart Detect AI enables post-submission claims risk detection by identifying unusual billing patterns, potential member-provider collusion, abnormal visit frequencies, clinical inconsistencies, and location anomalies. This allows for earlier detection of hidden risks, targeted investigations, and reduced financial leakage. For healthcare providers, the platform enhances pre-submission claim validation by flagging errors such as missing documentation, incorrect coding, benefit mismatches, unjustified procedures, and incomplete clinical rationale.

Smart Detect AI evaluates patterns across the entire claims ecosystem, spanning providers, patients, and time. This enables deeper insights into billing behaviour, patient journeys, and interaction patterns.

Speaking at the launch, Head of Data Analytics at Smart Applications International Barbara Simiyu said healthcare systems process claims at scale, but critical risks often remain hidden. “Smart Detect AI introduces a new level of intelligence that enables stakeholders to move from reactive to proactive claims intelligence — strengthening transparency, improving efficiency, and ultimately protecting the integrity of healthcare systems,” she noted.

The solution officially unveiled at the 5th Smart Summit.