MedForensix deploys 55+ AI forensic rules across your claims data in seconds - detecting Fraud, Waste & Abuse for scheme administrators across Africa and global markets.
Our engine processes every claim against 55+ forensic rules simultaneously. Watch it work.
Each rule outputs a Risk Score and Confidence Level - prioritising the highest-value flags for your investigators.
Identifies claims submitted more than once for the same member, procedure, provider and date - with full evidence trail.
Flags procedure codes claimed after their valid-until date using publication-aware tariff lookups across 23 code databases.
Detects members obtaining the same medication from 3+ pharmacies within 30 days - key indicator of drug diversion.
Flags claim amounts that deviate significantly from statistical norm using sigma-based outlier detection calibrated per scheme.
Validates hospital claims against applicable tariff rules - theatre classification, anaesthetic time, prosthesis mark-up and 20 more checks.
Flags claims submitted while a member's policy is TERMINATED or SUSPENDED - clear eligibility fraud indicator across all markets.
Real-time flag counts, potential loss estimates and per-claim confidence scores - all in one panel.
| Claim # | Member | Rule Triggered | Severity | Amount at Risk | AI Confidence |
|---|---|---|---|---|---|
| CLM-00841 | M. Dube | Duplicate Submission | 🔴 Critical | $2,400 | 92% |
| CLM-00792 | F. Moyo | Expired Procedure Code | 🔴 Critical | $1,850 | 87% |
| CLM-00715 | S. Chikwanda | Prescription Shopping | 🟡 Warning | $950 | 74% |
| CLM-00688 | T. Okafor | Statistical Outlier | 🟡 Warning | $600 | 68% |
| CLM-00634 | A. Mensah | Inactive Policy | 🔵 Info | - | 45% |
Visualise exactly which AI rules triggered which flagged claims - and how they connect.
Covering provider billing fraud, member fraud, hospital tariffs and regulatory compliance - adaptable to local tariff publications in every market.
Duplicate claims, outliers, code validation, surgical modifiers
Prescription shopping, overlapping visits, inactive policy
Theatre, anaesthetic, prosthesis mark-up, Appendix A–E
Stale claims, multiple claims prohibition, payment delays
Upload your CSV or Excel claims file to an investigation case. Multiple files supported per case, across any market or currency.
55+ neural forensic rules execute simultaneously. Pattern recognition, outlier scoring and confidence weighting - done in 30–90 seconds.
Each finding shows claim number, member ID, rule triggered, risk score and confidence - ranked by financial impact.
Generate a structured Excel report with per-rule worksheets and financial summaries ready for audit files and recovery letters.
MedForensix is engineered with multiple layers of security controls to protect your scheme's claims data at every stage.
TOTP and email OTP enforced on every login. Every user session protected by a second factor.
Super admin, org admin and auditor roles with strict data isolation per client organisation.
Every action logged with actor, IP and timestamp — providing a tamper-evident record for compliance reviews.
All data transmitted over HTTPS. HttpOnly, Secure and SameSite cookie attributes enforced at every endpoint.
IP-based rate limiting and auto-lockout after repeated failed login attempts safeguards against credential attacks.
Each scheme's data is fully isolated at the database level — zero cross-tenant data access is architecturally possible.
MedForensix is a specialist product within the Crediamo Technologies portfolio - a technology group building infrastructure for financial integrity, trust and transparency across African and emerging markets.
Get a personalised 30-minute walkthrough with one of our forensic specialists. We'll show you exactly how MedForensix detects fraud across your claims portfolio — live.
Our team will reach out within one business day to confirm your session time. Keep an eye on your inbox.
Purpose-built AI forensics for scheme administrators. Tariff-aware, enterprise-ready, and scaled for global markets.
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