FWA Mitigation

Better Data Prevents Premature Escalation

Most claims discrepancies stem from clerical oversights, misinterpretation of complex scheme rules, or unbundled billing codes—not fraudulent intent.
Smartchoice separates routine error resolution from adversarial fraud investigations. By letting schemes and practitioners identify and fix ordinary billing anomalies at ingestion, the platform resolves exceptions collaboratively—dramatically reducing the administrative overhead of post-payment clawbacks, provider disputes, and statutory complaints.

Controls Applied at the Right Stage

Smartchoice deploys targeted validations across the claims continuum to stop financial leakage before funds leave the scheme's account:

• Ingestion Screening (Smartchoice Exchange)
  Evaluate inbound claims against historical submission patterns, contracted provider registries, and pre-adjudication business rules the moment EDI files hit the switch.
• Historical Lookbacks & Duplicate Interception (Smartchoice Claims)
  Screen active submissions against settled claims history. The rule engine flags identical services, overlapping hospital stays, unbundled procedure codes, and frequency cap violations in real time.
• Deterministic Benefit & Tariff Evaluation
  Apply published scheme tariff schedules, Designated Service Provider (DSP) rates, and Prescribed Minimum Benefit (PMB) statutory rules automatically—preventing systematic over- or under-payment.
• Structured Clinical & Exception Routing
  Direct unresolved anomalies into dedicated assessor queues with line-item discrepancy notes, giving clinical auditors clear context for manual review without freezing unrelated claims.
• Financial Recovery & Settlement Tracking (Smartchoice Payments)
  Where the payments module is deployed, track identified overpayments, manage agreed provider refunds, and reconcile claim-linked offsets with transparent, auditable remittance advices.

Governance & Compliance

"A billing discrepancy is not evidence of fraud."

In line with the findings and recommendations of the Council for Medical Schemes (CMS) Section 59 Investigation, Smartchoice enforces objective, transparent distinction between operational coding anomalies and matters requiring formal forensic investigation.

• Explicit Discrepancy Reason Codes: Tell providers exactly why a line item failed validation, giving them objective data to resubmit a clean correction.
• Audit-Proof Decision Logging: Every rule check, assessor override, and exception review is permanently recorded with timestamps and user credentials.
• Protection Against Arbitrary Withholding: Prevents blanket, unverified payment suspensions under Section 59(3), ensuring that payment withholding occurs only through documented, legally sound governance channels.