AI healthcare fraud detection and prevention

Payment integrity before the claim becomes leakage.

Quantilae is built for payers and healthcare organizations that need earlier detection of suspicious billing patterns, coding abuse, provider anomalies, duplicate claims, and repeated small leakages across high-volume claim environments.

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U.S. market problem

$100B+ sits inside the U.S. healthcare fraud and payment-integrity problem.

Quantilae is aimed at the claim environment where fraud, waste, abuse, duplicate billing, coding manipulation, and improper payments create material leakage across Medicare, Medicaid, commercial plans, and adjacent payer workflows.

$100B+

Healthcare fraud, waste, abuse, and improper-payment exposure across Medicare, Medicaid, and adjacent U.S. payer workflows - the exact kind of payment-integrity problem Quantilae is designed to detect earlier.

claim anomalies provider pattern detection pre-payment review

Official sources

Government references grounding the scale and urgency of the problem.

White House

“Eliminating Waste, Fraud, and Abuse in Medicaid.”

White House source

“State Directed Payments have rapidly accelerated, quadrupling in magnitude over the last 4 years and reaching $110 billion in 2024 alone.”

GAO

“Medicare and Medicaid: Additional Actions Needed to Enhance Program Integrity and Save Billions.”

GAO source

“Both Medicare and Medicaid are susceptible to payment errors-over $100 billion worth in 2023.”

Platform logic

Not just “reject the claim.” Explain why it looks wrong.

Code intelligenceFlags suspicious CPT/HCPCS/ICD patterns, unbundling, upcoding, medically unlikely combinations, and repeated claim behavior.

Provider behaviorCompares providers against peer patterns, geography, specialty, claim mix, frequency, and historical risk movement.

Pre-payment preventionDesigned to surface questionable claims before payment, not only after money has already leaked out.

Explainable scoringRisk scores are supported by clear drivers so investigators can understand the signal instead of staring at a black box.

Low implementation burdenCloud-based intake designed around claim files, API connections, and payer workflows instead of heavy enterprise replacement projects.

Audit trailCreates a record of alerts, review decisions, reasons, and outcomes for management, compliance, and investigation teams.

Provider 418291

Repeated add-on codes74

Duplicate billing cluster63

Risk drivers: peer deviation, procedure frequency spike, same-day service pattern, modifier inconsistency.

Investigation-ready output

From signal to decision.

Quantilae should help teams move from raw claim noise to usable intervention: hold, review, request records, approve, deny, or escalate for investigation.

Early access

Submit your interest.

For payers, TPAs, Medicaid-related organizations, payment-integrity teams, healthcare fraud investigators, and strategic partners interested in early access or pilot discussions.