Processes
Manage fraud, abuse, and payment integrity
How manage fraud, abuse, and payment integrity are reshaped as AGI capability advances.
ProcessesManage fraud, abuse, and payment integrity
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Manage fraud, abuse, and payment integrity sits inside a larger value-flow — 1 parent structure it composes into. The hierarchy is grounding, not the story: it tells you which aggregate exposure Manage fraud, abuse, and payment integrity inherits.
Where Manage fraud, abuse, and payment integrity sits
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How the work flows
Trigger: A medical claim is submitted for payment or an anomaly is detected in provider billing patterns.
- Ingest claim data and historical billing records
- Execute automated payment integrity rules
- Flag suspicious claims or provider behaviors
- Conduct clinical and administrative investigations
- Recover overpayments or deny improper claims
- Update detection rules with verified patterns
Outcome: Fraudulent or abusive claims are denied or recovered and valid claims are cleared for accurate payment.
Measured by
False Positive RateTotal Recovered OverpaymentsFraud Detection RateInvestigation Cycle Time