Commercial payers
Pre-payment scoring to hold suspect claims for review before dollars go out.
Payer Integrity · AI Agent
Medical Billing Fraud Detection
The agent scores incoming and paid claims for fraud, waste, and abuse using anomaly and graph machine learning, surfacing the suspicious few for a Special Investigations analyst instead of leaving them buried in millions of clean lines.
Human-in-the-loopHIPAA-ReadyAudit LoggedExplainable ML
Trusted by global innovators
Fraud hides in the volume
Payers adjudicate millions of claims, and the fraudulent, wasteful, or abusive ones — upcoding, unbundling, phantom billing, collusive rings — are a tiny fraction hidden in the flood. Rules-only edits catch obvious patterns and miss adaptive ones; manual review can only sample. The agent narrows the haystack: anomaly models flag claims and providers that deviate from peer and historical norms, and graph ML surfaces suspicious relationships across providers, members, and referrals. Each flag is scored, explained, and routed to a Special Investigations analyst — the agent never denies a claim or accuses a provider on its own.
Anomaly + graph ML on the claim stream
Score, explain, and route the suspicious minority to investigators — with a human deciding every outcome.
Key Capabilities
Detection built for how healthcare fraud behaves — anomalies and relationships, not just static rules.
Anomaly detection
Scores each provider and claim against peer-group and historical baselines to catch upcoding, unbundling, and impossible-day billing rules miss.
Graph ML on relationships
Builds a graph of providers, members, and referrals to expose collusive rings, kickbacks, and identity misuse no single claim shows.
Claims-native scoring
Ingests X12 837 claims and 835 remittances with CPT/HCPCS, ICD-10, and modifier context so scores reflect real coding.
Explainable risk scores
Every flag carries the features that drove it — codes, peers, relationships — so investigators act on evidence, not a black box.
Investigator review gate
Flags route to Special Investigations for a human decision; the agent prioritizes and explains, never denies or sanctions automatically.
Who runs it
Deployment scenarios
The same agent, aimed at where payer losses concentrate.
Medicaid & Medicare plans
Program-integrity screening tuned to public-program billing patterns and rules.
Special Investigations Units
A ranked, evidenced queue that replaces sampling with prioritized casework.
TPAs & self-funded plans
FWA detection for administrators managing claims on behalf of employers.
Provider-network integrity
Graph analysis to surface collusive referral and billing rings across a network.
Post-payment recovery
Retrospective scoring of paid claims to target audit and recoupment efforts.
Expected impact once the agent is live
Directional targets measured on your own claims, never fabricated.
Ranked
Suspicious claims prioritized by explained risk
Fewer
False positives on honest, high-volume providers
1 gate
Investigator decision on every flagged case
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards it speaks
Data and controls
X12 837X12 835CPT/HCPCSHIPAASOC 2
How It Works
Ingest → score → explain → route
A four-stage pipeline that turns a flood of claims into a ranked, evidenced queue for investigators.
1.
Ingest claims
The agent ingests X12 837 claims and 835 remittances, plus provider and member reference data, into a governed, PHI-secured pipeline.
837 / 835 intake
2.
Score anomalies & graph
Anomaly and graph ML models score each claim and provider and surface suspicious relationships, flagging uncertainty.
Anomaly + graph ML
3.
Explain & route
Each flag is packaged with its driving features and routed to a Special Investigations analyst, who confirms, clears, or escalates.
Sign-off required
4.
Record & learn
The decision and rationale are written back to case management, and the outcome feeds model retraining.
System write-back
Related proof of compliant AI delivery
Read Case StudyLera Health: compliant women's health platform
A different domain, not a payer-integrity deployment, but it shows how we engineer AI on sensitive data: privacy-first architecture, consented flows, and human-reviewed outputs.
Compliance & Guardrails
15-Minute Scoping CallGuardrails on every flag
An investigator owns every consequential decision, and every score can be explained and audited.
PHI handling
Claims and member data stay in HIPAA-ready, encrypted infrastructure under a BAA, with least-privilege access scoped to the investigations team.
Human-in-the-loop
Every flag is decided by a Special Investigations analyst; the agent scores and prioritizes, never acts against a provider on its own.
Explainability
Each score exposes the anomalies and relationships behind it, so decisions withstand provider appeals and regulatory scrutiny.
Audit logging
Every score, flag, review, and outcome is timestamped and attributed for a defensible record.
Frequently Asked Questions
Yes. Claims and member data stay in HIPAA-ready, encrypted infrastructure under a signed BAA, with least-privilege access and full audit logging of every score and decision.
Ready to catch fraud the rules miss?
Tell us your lines of business and the fraud types that hurt most. We'll return an architecture plan with anomaly and graph ML detection and an investigator-in-the-loop workflow.
contact@agnotic.com
Partnerships
contact@agnotic.com