Fraud, waste, abuse, and claims-leakage intelligence for payer operations.
ArqFWA is a payment-integrity intelligence layer for healthcare payers. It reads across claims, providers, policy, and member context to surface the cases most likely to be fraud, waste, abuse, or leakage — and explains the reasoning clearly enough for an investigator to act on and defend.
Built for: Healthcare payers, TPAs, PBMs, and program-integrity teams
Payment-integrity teams are buried in claim volume, brittle rules, and cases that arrive too late to protect margin. The highest-risk patterns sit across claims, providers, policy, and member context — and no single system sees all of it.
ArqFWA prioritizes the cases worth human attention, explains why they matter, and keeps the evidence trail clean enough for downstream recovery and audit.
A reusable workflow spine, tuned to your data, systems, and controls — not a generic model wrapper.
Correlates billing patterns, provider behavior, and member history into one risk picture instead of thousands of isolated rule hits.
Every flagged case carries the evidence, peer comparisons, and policy references a reviewer needs — no black-box scores.
Builds a longitudinal view of each provider so emerging risk is visible before it compounds into material leakage.
Routes the highest-value cases to investigators with context, suggested next steps, and a clean, exportable audit trail.
Learns from investigation outcomes and recoveries so prioritization keeps sharpening against your real results.
Accelerators move fastest when the first release is narrow, measurable, and connected to the people who own the work.
Load a sample claims and provider-history slice.
Calibrate risk signals against known leakage and investigation outcomes.
Deploy a reviewer workbench with explanations, evidence, and routing.
Expand from sampled review to active queue prioritization.
Hold high-risk claims for review before payment leaves the door, with rationale your edits team can stand behind.
Surface paid-claim patterns worth pursuing for recovery, provider education, or audit.
Assemble defensible evidence packages for provider audits in minutes instead of weeks.
Built from payer fraud, waste, abuse, and claims-review patterns already appearing across ArqAI healthcare work, with governance-first review loops and auditable recommendations.
