Fraud & Abuse Management
Catch anomalies in health and non-life claims in real time, with AI.
JFraud catches fraud, leakage and abuse in real time across health and non-life lines using AI. With average-cost models built on ICD-10 and specialty data, it flags out-of-range cases as anomalies and prevents leakage within the provider network. Pre- and post-claim auditing stops financial loss at the source and points investigators at genuinely risky cases.
AI anomaly detection in health and fire lines
Cost-deviation analysis by ICD-10 and specialty
Leakage and abuse prevention within the network
Real-time pre- and post-claim auditing
Modules & Components
Modules within the family — working together or standalone.
JAnomaly for Health Insurance
Flags out-of-range cases as anomalies by computing average costs from ICD-10 and specialty data.
JAnomaly for Fire Insurance
Detects production and claims anomalies in fire and non-life lines.
JBlock for NW Leakage
Prevents leakage by identifying and blocking gaps and abuse within the health network.
JMediRadar
Instantly detects mismatches between diagnosis codes and requested services.
A leading insurer with a large corporate-health portfolio
Abuse PreventionChallenge
Unusually high-value claims and recurring abuse patterns slipped past manual review.
Solution
JFraud’s JAnomaly module scored every claim against an ICD-10 and specialty cost model; suspicious cases were auto-flagged and routed to investigation.
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