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Provider Fraud Intelligence

Detects anomalous billing and referral patterns across providers using network analysis, upcoding/unbundling detection, and peer-benchmarked billing profiles. Ranks providers by fraud-risk score and potential recovery value, auto-generates investigation-ready evidence packets, and tracks savings from flagged and recovered claims for payer SIU teams.

Provider Fraud Intelligence — Pragyan Ai

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Diagnostic Capacity Intelligence

Forecasts diagnostic equipment and lab capacity demand (imaging slots, pathology throughput, bed-side testing) against actual utilisation, surfacing bottleneck modalities and shifts before wait times spike. Ranks departments by capacity strain, recommends staffing and slot-allocation adjustments, and models the throughput impact of adding capacity — giving hospital operations teams a forward view of diagnostic bottlenecks.

Pre-Submission Claim Intelligence

Scans insurance claims before submission for coding errors, missing documentation, and denial-risk patterns learned from historical payer behaviour. Scores every claim by approval probability, flags the specific fields likely to trigger rejection, and recommends corrections — reducing first-pass denial rates and accelerating reimbursement cycles for the revenue cycle team.

Pharma Demand Intelligence

Forecasts pharmacy and drug demand at SKU level using patient census trends, seasonal disease patterns, and prescription velocity. Flags stockout and overstock risk ahead of time, recommends reorder quantities and timing per drug and location, and tracks forecast accuracy against actual consumption — reducing both stockout-driven care delays and expired-inventory wastage.

Pathology Quality Intelligence

Monitors pathology and lab result quality using turnaround-time tracking, critical-value alerting, and inter-lab variance detection to catch quality drift before it affects diagnosis. Flags labs and technicians trending outside quality control bounds, ranks error patterns by clinical risk, and generates quality-improvement briefs for lab management.

OT/OPD Optimisation Engine

Optimises operating theatre and outpatient department scheduling by forecasting case-length variance, no-show probability, and resource conflicts across surgeons, rooms, and equipment. Recommends schedule adjustments to cut idle OT time and OPD wait times, models the throughput impact of proposed changes, and tracks utilisation and patient-wait-time improvements over time.

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