Live streaming anomaly detection for prescription claims processing, flagging formulary violations, spread pricing irregularities, and specialty drug overcharges as they occur.
Every claim tested against 200+ fraud patterns, pricing benchmarks, and contract rules within seconds of adjudication. Machine learning flags statistical outliers and known leakage schemes.
High-value violations (>$10K) trigger immediate Slack/Teams notifications to plan administrators. Medium alerts queue for weekly review. Low-priority patterns tracked for trend analysis.
AI learns normal claim patterns for your population. Detects subtle shifts—gradual spread increases, new specialty drugs appearing without prior auth, or MAC pricing drift—before they compound.
Watch claims flow through the system in real-time. See exactly when a high-cost specialty claim hits, what price was paid, and whether it violated contract terms—no waiting for monthly reports.
Flag claims where ingredient cost plus dispensing fee exceeds contracted max. Catches AWP inflation, MAC overcharges, and undisclosed admin fees in real-time.
Alert when brand drug dispenses but generic equivalent exists on formulary. Detects DAW code abuse and verifies medical exceptions have proper prior authorization.
Compare specialty drug prices to manufacturer WAC, 340B ceiling prices, and Mark Cuban Cost Plus benchmarks. Flag claims exceeding reasonable markup thresholds.
Comprehensive governance framework for board members and plan fiduciaries — defense-ready documentation and continuous oversight infrastructure.
Timestamped audit trail with complete chain of custody
EBITDA quantification and board-ready financial models
Cross-system verification and data integrity validation
Automated clause extraction and guarantee enforcement
Monte Carlo simulations and credibility-weighted forecasts
Transaction-level anomaly detection and forensic alerts
ERISA compliance monitoring and DOL audit readiness
AI-powered trend forecasting and intervention modeling