Diagnosis–Procedure Mismatch Detection
Validate the match between diagnosis codes and medical services in real time, via API.
JMediRadar is a specialist abuse-prevention engine that checks, in real time and via API, the match between diagnosis codes and requested medical services. It instantly detects procedures, tests, imaging and drugs inconsistent with the diagnosis — approving valid claims and rejecting inconsistent ones. It plugs into your existing claims system via API within seconds and complies with the strictest data-privacy rules.
Real-time diagnosis–procedure compatibility via API
Auto-rejection of services and drugs inconsistent with diagnosis
Reduced fraud-related financial loss
Full compliance with data-privacy regulations
Capabilities
Real-time Compatibility Check
Instantly compares the diagnosis code and requested service via API.
Automated Approve / Reject
Approves valid claims and automatically rejects inconsistent ones.
Leakage Prevention
Reduces financial loss by blocking non-compatible service requests.
Privacy Compliance
Operates in line with the strictest data-privacy regulations.
A health insurer processing high-volume outpatient claims
Outpatient ClaimsChallenge
Tests, imaging and drugs unrelated to the diagnosis inflated claim costs, and manual checks could not keep up.
Solution
JMediRadar was added to the claims flow via API; every claim was instantly checked for diagnosis–procedure compatibility and mismatches were rejected.
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