Healthcare
AI claims-integrity engine built for Avalon Health: every medical claim is scored for fraud, waste, and abuse before it is paid. Payer-side advisory scoring across 12 rule families plus ML anomaly detection, multi-tenant from day one. ClaimGuard is a payer-side claims-integrity engine Lioncap built for Avalon Health.
Medical aid societies lose significant money to fraud, waste, and abuse, but reviewing every claim by hand is impossible and blunt auto-denial rules create disputes and member harm.
Lioncap built ClaimGuard to score each claim through twelve deterministic rule families (unbundling, duplicates, tariff-specialty mismatches, eligibility, after-death claims and more) alongside peer-group statistics and a machine-learning anomaly model, with an OCR channel for paper claims.
Every verdict is advisory, approve, refer for review, or recommend deny, and lands in an investigator console with severity bands, dispositions, and an audit trail, so humans stay in control of every decision.