Health
Claims adjudicated straight from the medical record, so a hospital is paid on the treatment it can evidence.
Hospital electronic medical records (EMR)
Where it breaks today
A facility is contractually owed payment within 30 days of an accepted invoice.
A facility is contractually owed payment within 30 days of an accepted invoice. In practice it runs to weeks and months. Cashflow is planned around a queue nobody can see into.
Claims come back for resubmission over a missing field or an unreadable attachment. The clock restarts.
Fraud and duplicate billing are documented and hard to catch by hand, because the reviewer sees a form, not the encounter it came from.
Community-based health insurance runs a deficit it cannot diagnose, because the claim data arrives late and inconsistent.
What AXK does
The claim is read against the encounter in the electronic medical record. Diagnosis, procedure, and prescription are checked as a set, not as free text on a form.
Policy validity, benefit limits and exclusions are evaluated as rules, so a claim that cannot be paid is rejected at submission with the reason attached.
A fraud score is attached to every claim from billing patterns, duplicate encounters and provider history. Only the flagged ones go to a human.
Claims that clear the rules and the fraud model are approved without a reviewer touching them.
What it reads from
- Hospital electronic medical records (EMR)
- Insurer policy and benefit tables
- Community-based health insurance enrolment registers
- Mobile money and bank settlement rails
How it settles
The hospital is paid over mobile money or bank transfer once the claim clears.
The hospital is paid over mobile money or bank transfer once the claim clears. Every payment carries the claim id and the rule that approved it, so reconciliation is a lookup instead of a phone call.
The other lines
One engine, every line of insurance.
Building on health claims?
Tell us what the claim looks like today and what evidence you already have. We'll tell you honestly whether AXK's rules engine is a fit.