Inpatient Double Billing Detector HIGH RISK DRAFT INPATIENT
Inpatient Claims · Room Type: Private · Created by Marcus Chen
Rule Name & Description
When should this rule trigger? — Set your IF conditions
IF
INPATIENT
the a previous claim's
for the same within
Checks if the same surgery code appears twice in claim history for the same inpatient.
AND
the for this diagnosis
Flags stays exceeding clinical benchmark for the billed diagnosis — typical for inflated inpatient claims.
AND
the
Targets high-cost room categories where upcoding and over-billing are most prevalent.
AND
the
Only flags high-value inpatient claims — avoids noise from minor admissions.
What should happen when triggered? — Set your THEN action
THEN
4
Rule Summary — Plain English preview
IF the Surgery Code is the same as a previous claim's Surgery Code for the same Patient within 60 days,
AND the Length of Stay is greater than 7 nights for this diagnosis,
AND the Room Type is one of Private Room, Suite, VIP,
AND the Claim Amount is greater than HK$50,000 —
THEN Flag for Review with severity HIGH and assign to Senior Adjudicator Team.
Back Testing — Simulate rule against historical inpatient data
Historical Back Test
Select a period and run to see projected impact
NOT RUN
Back testing uses anonymised historical data — no live claims are affected.
INPATIENT TEST
Live
CLAIMS CHECKED 38,412
WOULD FLAG 2,847 (7.41%)
EST. RECOVERY HK$6.2M