AI-Powered Intelligent Claim Recovery Workflow

AI Agents + UiPath Maestro + RPA Bots for Automated Claim Risk Screening, Payment Validation, Root Cause Investigation & Recovery

Ifrah Khan

Senior Manager

FirstSource Solution Limited

Ifrah.Khan@firstsource.com

Nihilkumar Thangavel

Karthick Raja A

Jothika KR

Team name : Firstsource Neural Squad�Project title ​ : AI-Powered Intelligent Claim Recovery Workflow

Manager

FirstSource Solution Limited

nihilkumar.thangavel@firstsource.com

Senior Executive

FirstSource Solution Limited

karthickraja.appavoopillai@firstsource.com

Executive

FirstSource Solution Limited

Jothika.Kr@firstsource.com

The Problem

• Brief summary of the solution and what makes it unique​
• High-level value prop or innovation angle

3

Current Claim Recovery Process is Manual, Time-Consuming, and Prone to Payment Errors.

Business Challenges

Claims are manually reviewed to identify overpayments and underpayments, resulting in slower investigations and inconsistent decisions

Analysts manually compare billed, allowed, and paid amounts across multiple systems to identify payment discrepancies.

Claim details, provider information, diagnosis codes, and payment history are spread across multiple applications, increasing investigation time.

Determining the cause of payment variances relies heavily on experienced analysts, leading to inconsistent outcomes and longer resolution cycles.

2–5 Days

Average time to complete a payment variance investigation.

70%

Of analyst effort is spent collecting claim information instead of resolving payment issues.

1 in 8 Claims

Require additional investigation due to payment discrepancies, eligibility issues, duplicate payments, or pricing errors.

The Solution

An AI-powered UiPath Maestro workflow that automates claim risk screening, payment validation, root cause investigation, and recovery execution using AI Agents, MCP tools, RPA bots, and Human-in-the-Loop.

1

Intake & Screening

RPA imports the daily recovery report.MCP tools retrieve claim details.AI evaluates predefined high-risk conditions.Only high-risk claims proceed for investigation.

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2

Detection & Validation

Compare Paid Amount with Expected Amount. Detect Overpayment or Underpayment. Calculate payment variance. Identify claims requiring further investigation.

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3

Root Cause Investigation

Analyze claim details and payment variance. Identify the most likely root cause. Generate AI recommendations with confidence score. Suggest recovery or reimbursement actions.

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4

Recovery & Approval

Human reviewer approves or rejects recommendations. RPA updates the Claims Application. Execute recovery or supplemental payment. Generate audit trail and notifications.

5

Benefits and technologies used

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Benefits, impact and outcomes

• 80% Faster Claim Investigation AI agents automatically screen claims, detect payment variances, and investigate root causes, significantly reducing manual effort.
• Improved Payment Accuracy Automatically identifies overpayments and underpayments by comparing expected and paid amounts using configurable business rules.
• End-to-End AI Automation UiPath Maestro orchestrates AI Agents, MCP tools, RPA bots, and Human-in-the-Loop approval in a single intelligent workflow.
• Reduced Manual Review High-risk claims are automatically prioritized, allowing analysts to focus only on cases that require human judgment.
• Complete Audit Trail Every investigation, AI recommendation, approval decision, and recovery action is logged for compliance and traceability.
• Faster Recovery Processing Approved recovery actions are executed automatically, including claim updates, notifications, and audit report generation.

AI-Powered Claim Recovery Process

Powered by UiPath Maestro, AI Agents, MCP Tools & RPA Bots

KEY:

UiPath RPA

AI Agent (LLM)

API / Integration

Human (HITL)

Process Flow

Control / Feedback

CONTROL TOWER

TIER 1

BUSINESS PROCESS FLOW

TIER 2

TECHNOLOGY EXECUTION

UiPath, AI agents, APIs powering the process

TIER 3

GOVERNANCE & CONTROL

Policy, monitoring & audit

1

Claim Intake

Daily Recovery Report Claim ID received

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2

Risk Screening

Retrieve claim details Evaluate high-risk conditions

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3

Payment Validation

Compare Expected vs Paid Amount Detect Overpayment / Underpayment

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4

Root Cause Investigation

Identify root cause Generate confidence score

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5

Evidence Collection

Fetch provider details Retrieve diagnosis information

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6

Human Approval

Review AI recommendation Approve / Reject

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7

Recovery Execution

Update Claims Application Execute recovery/supplemental payment

AI Screening Agent

• High-risk classification Rule evaluation Intelligent routing

CARRIER MESH

API Carriers

• Send JSON payload
• FastAPI endpoints

Detection & Validation Agent

• Expected amount calculation Variance detection

Recovery Intelligence Agent

• Root cause analysis AI recommendations

Governance Gate

Risk < Threshold?

YES → auto-proceed

NO → Human Review

Recovery Bot

• Claims update Recovery execution Audit generation Notifications

Orchestrator

Workflow, queues, exceptions

Rules Engine

Business, risk & validation rules

Action Center

Human tasks, SLAs, escalations

Data & Audit Store

Golden records, immutable logs

Monitoring

KPI dashboards, process mining

Compliance

HIPAA, SOC2, RBAC

UiPath Orchestrator

Workflow control & monitoring

UiPath AI Center

LLM services & agent management

Business Rules Engine

Policies & thresholds

HITL

Human tasks & escalations

Data Service / DB

Quotes, documents, audit data

Compliance & Security

HIPAA, SOC2, RBAC

Proposal Agent + Delivery Bot

Inside the Agents

Three specialized AI agents working together to automate healthcare claim recovery from risk screening to payment validation and root cause investigation..

Screening Agent

Retrieves claim details using MCP tools.

Evaluates predefined high-risk screening rules.

Identifies claims with potential payment risks

Routes High-Risk claims to the Detection & Validation Agent.

Output: High Risk (Yes/No)

Detection & Validation Agent

Calculates the expected payment amount.

Compares Expected Amount vs Paid Amount.

Determines Recovery Type (Overpaid / Underpaid / No Variance).

Calculates payment variance

Output: Recovery Type + Expected Amount + Paid Amount + Variance Amount

Recovery Intelligence Agent

Analyzes payment variance and claim details.

Identifies the most probable root cause.

Generates AI-powered recovery recommendations.

Provides a confidence score for the identified cause.

Output: Root Cause + AI Recommandation + Confidence Score

8

Humans Stay In Charge

UiPath Action Center empowers claim analysts to review AI recommendations, approve recovery actions, request additional investigation, or reject recommendations while maintaining complete auditability.

Complete Audit Trail

Every AI decision, confidence score, reviewer action, and recovery execution is automatically logged to ensure full traceability and compliance.

Human Review & Escalation

High-risk or complex claim recovery cases are automatically assigned to the appropriate claim's analyst for review and approval.

AI-Assisted Decision Making

Analysts review AI-generated root causes, recovery recommendations, and confidence scores before approving, rejecting, or requesting additional investigation.

From Claim Screening to Recovery Decision Faster, Smarter, and Fully Auditable.