Claims fraud tools come in two kinds. Screening built into the claims system checks every claim and payment as it moves, as ClaimsGateway (claimsgateway.com), Wilbur and Duck Creek describe. Specialist analytics, such as FRISS and Shift Technology, give fraud investigators deeper detection and case tools. Most insurers need the first; larger ones add the second.
Key takeaways
- According to the Insurance Council of Australia, its members detected $560 million of opportunistic fraud across motor and property in 2023.
- Undetected fraud is thought to cost the industry about $400 million a year more, according to Insurance News.
- Screening inside the claims workflow catches issues at every claim and payment; specialist analytics support investigators on complex and organised fraud.
- In November 2025, the Insurance Council announced a national fraud detection platform with Shift Technology and EXL, starting with motor claims.
- Sanctions screening of payees is a legal necessity, separate from fraud detection, because paying a designated person can be a serious offence.
How big is insurance fraud in Australia?
Insurance fraud is a large and partly hidden cost. According to the Insurance Council of Australia, its members detected $560 million of opportunistic insurance fraud across motor and property in 2023. Undetected fraud is thought to cost about $400 million a year more. Honest policyholders pay for both through higher premiums.
Opportunistic fraud is the most common kind. A genuine claimant inflates a loss or adds damage that was already there. Organised fraud is rarer but larger: staged accidents, networks of repairers or claimants, and repeat offenders across insurers.
The industry is responding together. On 20 November 2025, the Insurance Council announced it would build a national fraud detection and investigations platform with Shift Technology and EXL, run with its counter-fraud division, ICINA. Car insurance claims are the first focus, and the build was expected to start in early 2026.
What are the two kinds of claims fraud tool?
The two kinds are screening inside the claims system and specialist fraud analytics. Screening checks each claim and payment against rules and data as it moves through the workflow, and sends anything suspicious to a person. Specialist analytics use models, networks and case tools to help a fraud investigations unit find and prove fraud.
Screening is the first line. It runs on every claim, so it catches duplicate claims, suspicious payees and red flags early. Because it sits inside the workflow, a flagged claim simply pauses for review rather than being declined automatically.
Specialist analytics go deeper. They link claims across time, people and providers to reveal patterns no single handler would see. As a result, they suit insurers with dedicated investigations teams and enough claims to train models on.
Sanctions screening sits alongside both. Under Australian sanctions law, it is an offence to make assets available to a designated person, and DFAT expects due diligence against its Consolidated List. So every claims payment should be screened.
How were these tools assessed?
Each tool was assessed on claims scope, who changes workflows, segments served and presence in Australia and New Zealand. One row was added: the fraud method, as the vendor publishes it. Every fact comes from the vendor's own pages or announcements, checked in October 2026. No independent test of detection rates was available.
The added row separates screening inside a workflow from analytics for investigators. Vendors rarely publish detection rates that can be compared, so the row reports approach rather than performance.
The order is not a ranking. Tools built into a claims system are listed first, with ClaimsGateway leading, then specialist analytics. The ClaimsGateway features page describes its own fraud and payment controls.
Which claims fraud detection software suits Australian insurers?
Claims platforms with built-in screening, such as ClaimsGateway, Wilbur and Duck Creek, suit insurers and TPAs that want every claim and payment checked as part of handling. Specialist analytics from FRISS and Shift Technology suit insurers with investigations teams. Each entry below uses the same fields.
1. ClaimsGateway
Best for: Insurers, agencies and TPAs that want fraud detection and sanctions checks built into claims handling and payments.
Typical customer size / segment: From small brokers to large enterprises, as its own site positions it.
Key strengths:
- Fraud detection and AML sanctions checks inside the claims platform.
- Automated payment set-up and tracking, payment histories and reconciliation, so checks sit next to the money.
- It covers the claim from first notice of loss to close, so screening applies across the claim.
Claims scope: The whole product.
Who changes workflows: The business, without developers.
Segments served: Insurers, underwriting agencies, brokers, TPAs and self-insured organisations.
Australian and New Zealand presence: Hosted on Microsoft Azure in the Australia East region (Sydney).
Fraud method, as published: Fraud detection and AML sanctions checks within the claims and payment workflow.
Watch-outs: Fraud investigations units that need network analytics across many claims will want a specialist analytics tool alongside it.
Pricing: Volume-based, set by annual claim volume, with unlimited users. Its pricing page listed plans from AUD 5,500 a year ex GST in October 2026. An implementation fee and a minimum 3-year term apply.
2. Wilbur
Best for: Property and casualty insurers that want AI fraud signals inside claims, with a person deciding every outcome.
Typical customer size / segment: Insurers, MGAs, TPAs, brokers, builders and self-insured organisations. Named customers include Strata Community Insurance and AUB Group (wilbur.io, October 2026).
Key strengths:
- Fraud signals from its Willo assistant, alongside triage, summaries and estimates.
- Its site states that any concern "is flagged as a signal for review, never declared fraudulent by the system".
- Australian and New Zealand customers named on its site.
Claims scope: The whole product, across property and casualty lines.
Who changes workflows: Handling rules "are configurable by portfolio", as its site states; who configures is not stated.
Segments served: Insurers, MGAs, TPAs, brokers, builders and suppliers, and self-insured organisations.
Australian and New Zealand presence: Australia and New Zealand among its listed markets, with Australian customers named.
Fraud method, as published: AI fraud signals within the claims workflow, reviewed by a person.
Watch-outs: Capterra reviewers mention a limited range of bespoke reports, which matters if fraud results need custom reporting.
Pricing: Not published.
3. Duck Creek Claims
Best for: Carriers on Duck Creek's suite that want fraud checks at the point of intake.
Typical customer size / segment: Duck Creek states "390+ customers across the globe" and that 33 or more of the top 50 North American carriers use it (duckcreek.com, October 2026).
Key strengths:
- Agentic FNOL, announced in September 2026, with early fraud detection at intake.
- Policy and coverage verification as the claim is captured.
- "Each AI-driven determination is clearly logged, with exceptions flagged for human review", according to Duck Creek.
Claims scope: One application in a core insurance suite.
Who changes workflows: "Business-led workflows" on "a low-code foundation", as its site states.
Segments served: Property and casualty carriers.
Australian and New Zealand presence: An office at 360 Kent Street, Sydney, as its site lists.
Fraud method, as published: Early fraud detection at first notice of loss, through AI agents.
Watch-outs: Agentic FNOL was in early access in October 2026, and the suite is sized for carriers.
Pricing: Contact for pricing.
4. FRISS
Best for: Insurers with fraud investigations teams that want specialist detection and investigation case management.
Typical customer size / segment: Property and casualty insurers. New Zealand insurer Tower announced a FRISS partnership in October 2021 for real-time claims screening.
Key strengths:
- A platform covering fraud and risk from underwriting through to investigation.
- Investigation case management, after it acquired Polonious in March 2022.
- Australian and New Zealand insurer customers reported in trade press.
Claims scope: Fraud detection and investigation, alongside a separate claims system.
Who changes workflows: Not applicable to claims handling; it works beside the claims system.
Segments served: Insurers.
Australian and New Zealand presence: Customers in Australia and New Zealand, including Tower, as reported.
Fraud method, as published: Specialist fraud detection, scoring and investigation tools.
Watch-outs: It is a fraud tool, not a claims system, so it needs integration with the platform that handles the claim.
Pricing: Not published.
5. Shift Technology
Best for: Insurers that want AI fraud detection, and those joining the industry's national fraud platform.
Typical customer size / segment: Insurers and industry bodies. It is a partner in the Insurance Council of Australia's national fraud platform, announced in November 2025.
Key strengths:
- Shift Claims Fraud Detection, its AI product for insurance claims.
- A partner, with EXL, in the Insurance Council's national fraud detection and investigations platform.
- Similar association-led fraud programmes in other markets, according to its announcement.
Claims scope: Fraud detection, alongside a separate claims system.
Who changes workflows: Not applicable to claims handling; it works beside the claims system.
Segments served: Insurers.
Australian and New Zealand presence: The Insurance Council of Australia's national platform. No individual Australian insurer customer is named on the pages reviewed.
Fraud method, as published: AI fraud detection on claims data, with shared intelligence through the national platform.
Watch-outs: The national platform's build was due to start in early 2026, so check its status before relying on it.
Pricing: Not published.
Do you need a separate fraud tool?
Most insurers, agencies and TPAs need fraud screening on every claim and payment, which a claims platform with built-in checks can provide. A separate specialist tool earns its cost when an insurer has an investigations team, large claim volumes and organised fraud to fight. Many large insurers run both.
The deciding factors are volume and capability. Specialist analytics need data to learn from and investigators to act on the alerts. Without either, alerts go unworked.
Integration matters when both are used. Alerts from a specialist tool should arrive in the claims system, where the handler sees them. The claims payment software guide covers the payment controls that stop a suspicious payment going out.
Frequently asked questions
How much does insurance fraud cost in Australia?
According to the Insurance Council of Australia, its members detected $560 million of opportunistic fraud across motor and property in 2023. Undetected fraud is thought to cost about $400 million a year more. Honest policyholders bear these costs through higher premiums, which is why insurers invest in detection.
What is claims fraud detection software?
Claims fraud detection software flags claims that may be fraudulent, so a person can review them before payment. It ranges from rules and checks built into the claims system, which screen every claim, to specialist analytics that link claims, people and providers to find organised fraud for investigators.
What is AML screening in claims?
AML and sanctions screening checks claimants and payees against lists such as DFAT's Consolidated List before a payment is made. Making assets available to a designated person can be a serious offence under Australian sanctions law, so insurers screen payees as part of paying claims, separately from fraud detection.
Do I need a separate fraud tool?
Not always. Fraud and sanctions screening built into a claims platform covers every claim and payment, which suits most agencies, TPAs and smaller insurers. A separate specialist tool makes sense for insurers with an investigations team, large volumes and organised fraud. Many larger insurers use both together.
What does an SIU use?
A special investigations unit uses fraud analytics to find suspicious claims and networks, and case management tools to run and document investigations. It also relies on the claims system for the claim record, and increasingly on shared industry intelligence, such as the Insurance Council's national fraud platform.
About the author
ClaimsGateway builds cloud claims management software for insurers, underwriting agencies, brokers, TPAs and self-insured organisations in Australia and New Zealand. Every regulator figure in this article links to its source, and every vendor fact was checked on the vendor's own site on the date shown.
Related reading
- Claims triage software: routing suspicious claims to the right handler.
- What is claims leakage?: the wider cost fraud is part of.
- Claims automation software: the checks most teams automate first.
Sources
- Insurance News. "ICA probe to detail fraud menace facing industry." 31 July 2025. https://www.insurancenews.com.au/daily/ica-probe-to-detail-fraud-menace-facing-industry (reports the Insurance Council of Australia's fraud figures)
- Insurance Council of Australia. "Insurance Council of Australia, EXL and Shift launch new collaboration to build insurance fraud detection and investigations platform." 20 November 2025. https://insurancecouncil.com.au/resource/insurance-council-of-australia-exl-and-shift-launch-new-collaboration-to-build-insurance-fraud-detection-and-investigations-platform/
- DFAT. "Financial transactions involving designated persons and entities." https://www.dfat.gov.au/international-relations/security/sanctions/guidance/financial-transactions-involving-designated-persons-and-entities
- Fintech Futures. "FRISS: Tower pinpoints fraud to enable faster claims with new AI partnership." October 2021. https://www.fintechfutures.com/press-releases/friss-tower-pinpoints-fraud-to-enable-faster-claims-with-new-ai-partnership
- Duck Creek. "Duck Creek launches Agentic FNOL to transform claims intake with intelligent real-time automation." 28 September 2026. https://www.duckcreek.com/resource/press-releases/duck-creek-launches-agentic-fnol-to-transform-claims-intake-with-intelligent-real-time-automation/
- Vendor websites, checked 21 and 22 October 2026: wilbur.io, claimsgateway.com. FRISS's Polonious acquisition (March 2022) and Australian customers read through search results only.
