S/N 5 – Risk-based QA Sampling

MediConCen FWA QA Engine

HK Medical Insurance / Risk-based QA Sampling

Dashboards: 1 2 3 4 5 6 7 8 9

QA ENGINE LIVE

Cycle: Jun 2025

High Risk Score

Risk score ≥ 75 (RED RAG)

≥ 75 sampling rate 100%

High Claim Value

Claim amount > HK$80,000

> HK$80K 30%

New Assessor

Assessed by staff < 90 days tenure

< 90d tenure 50%

New Provider

Provider onboarded < 6 months

< 6mo 25%

Model Override

Assessor overrode ML recommendation

Override 75%

Weekend Claims

OFF

Submitted on weekends / holidays

QA owner: MediConCen FWA Operations team — independent assurance, separate from the AI's continuous learning. Criteria configurable; sampling rate auto-adjusts to capacity.

QA Case Queue JUNE 2025 4,821 ASSESSED

312

147

165

QA-25-00312 RISK 87 PENDING REVIEW

Underlying claim: CLM-25-074821 · Assessed by Marcus Chen · Jun 3, 2025 14:22

Why This Case Was Sampled

Original Assessment Decision

APPROVED

HK$142,000 paid

REJECT

Override detected

3 Triggered

All RED severity

4m 12s

Below avg (8m)

Assessor approved claim despite ML rejection and 3 active RED-severity rule flags. Assessment time was significantly below average, indicating possible inadequate review.

QA Review Checklist IN PROGRESS

Audit Trail

87.3%

↑ 2.1% vs May

12.7%

↓ 2.1% vs May

HK$3.4M

From failed QA

To investigations

ML Override Without Justification34%

Insufficient Document Review28%

Rule Flag Ignored21%

Incorrect Amount Approved17%

High Risk Score

68%

Model Override

52%

New Provider

31%

High Claim Value

18%

New Assessor

12%

Insight: Model Override criteria has the highest fail-to-pass ratio — assessors who override ML recommendations should be targeted for additional training.

QA CYCLE · JUNE 2025

Auto-sampling active

4,821

312(6.47%)

HK$3.4M

12.7%