Cost, Claims & Risk Management

Real-Time Care Navigation & Cost Steering

At the point of care, our solution calculates member-specific financial impact in real time and steers members toward appropriate, lower-cost care options.

The Digital Member Journey

1. Search: Find available providers by speciality, location, network status and appointment availability.

2. Compare: View network status, expected treatment cost, coverage conditions and care options side by side.

3. Calculate: Apply plan rules, accumulated deductible benefits, cost-sharing and provider tariffs in real time.

4. Steer: Highlight clinically appropriate, lower-cost care options and quantify expected member savings.

5. Authorise & Book: Trigger pre-authorisation (GOP) where required and book the appointment.

Precision Preventive Medicine

A physician-facing clinical decision-support tool that converts biological, genetic and questionnaire data into dynamic risk profiles and personalised prevention pathways.

Core Architecture & Technical Facts

Knowledge Architecture: Powered by 4 supervised generative AIs, 25 years of medical expertise, 10 consensus specialists, and 1,000+ algorithms.

Diagnostic Scope: Covers 75 medical conditions and 250 health topics, generating 150+ results per individual analysis.

Causal Bayesian Belief Networks: Structure medical knowledge into causal networks that connect risk factors, symptoms, tests, and disease probability.

Risk to Action: Stratifies risk into Low, Intermediate, and High, linking each level directly to physician-guided prevention pathways.

Scientific Authority: Medical & scientific board of experts in respective fields.

Digital Medical Selection & Underwriting

Automating routine health risk selection while keeping underwriting rules and data under full insurer control.

Key Differentiators

Structured Data at Source: Dynamic health questionnaires adapt to responses, capturing structured medical data directly without paper or manual re-keying.

Insurer-Controlled Rules: Insurer-approved decision rules govern all accept, load, exclude, postpone, or decline decisions.

Reinsurer Independence: Maintain full ownership of medical disclosure data and decision history, allowing you to change reinsurers without losing underwriting workflows or historical data.

Claims Administrator Performance Audit

Independent assurance over internal or outsourced claims adjudication against plan rules, pricing agreements, eligibility and service standards.