Prevent Fraud, Waste & Abuse Before Claims Reach Adjudication
Fraudulent or incorrectly coded claims drain resources, increase admin costs, and damage trust.
Health Code Index (HCI) identifies, validates, and flags non-compliant claims using built-in coding rules, clinical logic, and scheme-specific validations, before they ever reach your adjudication system.
The Challenge of eliminating Errors and Manual Oversight
All funders face the same problem; unnecessary costs caused by invalid or exaggerated claims. These often stem from:
- Duplicate submissions or unlinked follow-up claims.
- Misused RPL, ICD-10 and CPT-4/CCSA codes.
- Incorrect code, modifier or tariff combinations.
- Claims submitted with invalid or clinically inconsistent ICD-10 diagnoses.
Manual detection is slow, reactive, and error-prone.
HCI brings automation, consistency, and transparency to the process . We stop invalid claims before they’re paid.
The HCI Solution: Real-Time Fraud & Abuse Detection
Health Code Index integrates directly into your claims or billing system to apply hundreds of clinical, procedural, and tariff rules in real time — identifying coding or claim anomalies automatically.
How it works
Claims data is sent to HCI for validation.
Each claim is analyzed using CPT-4/CCSA, ICD-10, RPL, PMB/DTP, and tariff rule sets.
The system applies fraud and waste prevention logic to detect irregularities.
Non-compliant, duplicate, or suspicious entries are flagged instantly for review
Validated claims continue seamlessly to adjudication or payment.
“Stop chasing fraudulent claims after payment — prevent them before they happen.”
Benefits of Automated Fraud, Waste & Abuse Prevention
Outcome
What You Get
What HCI Checks For
Duplicate Claims & Double Billing
- Detects identical or overlapping submissions.
- Flags duplicate services within a defined timeframe.
Invalid or Inconsistent Coding
- Identifies mismatched ICD-10 and CPT-4/CCSA combinations.
- Detects non-viable modifier applications and tariff inconsistencies.
Upcoding & Overutilization
- Flags patterns of overuse or inappropriate procedure frequency.
- Detects codes applied outside of defined clinical norms.
Unbundling Detection
- Recognizes procedures that should be billed together under a composite code.
- Ensures correct use of modifiers and bundled payment logic.
Scheme-Specific Rules
- Applies funder-defined policies and payment arrangements automatically.
- Flags deviations from internal claims rules.
Integration Made Simple
- Works within your existing claims adjudication platform.
- One-time API integration maintained daily by SpesNet.
- Zero manual updates or development required.
- Scalable across multi-site hospital networks and schemes
Built-In Audit & Compliance
HCI records every rule applied, every flag raised, and every decision made — giving you complete audit visibility and defensible compliance.
- POPIA-compliant, encrypted data handling.
- Full traceability for all validation events.
- Exportable fraud-prevention and audit reports.
- Daily rule and logic updates by SpesNet.
Start Preventing Fraud Before It Starts
Stop investigating after the fact — automate prevention at the source.
HCI helps schemes and administrators detect and prevent fraud, waste, and abuse instantly.