CLM-25-091044
RISK 87
3 ALERTS
AMBER OVERRIDE
Chan Ming-Ho · M/52 · Policy HKPRU-2021-084421 · Inpatient Knee Surgery · HK$138,000
87
RISK
Overall Risk Classification
RED — HIGH RISK
Score driven primarily by duplicate billing pattern (ICD: M17.11, Code: HX-441) and amount 31% above P90 benchmark. Assessor override recommended — seek senior sign-off.
Prioritised Alerts
3 ACTIVE
MED
Amount 31% Above P90 Benchmark
BILLING
HK$138,000 vs P90 benchmark HK$105,200 for HX-441 at Gleneagles HK. Implant line item (HK$48,000) exceeds pre-auth scope.
Benchmark: P90=HK$105.2K
Invoice line 7: Implant
MED
OT Report Timestamp Anomaly
DOCUMENT
Operation Theatre report timestamped 2 hours after discharge time on discharge summary. Possible backdated documentation.
Discharge: 03 Jun 11:30
OT Report: 03 Jun 13:42
AI-Synthesised UW & Claim History
AI SUMMARY
Policyholder: Chan Ming-Ho, M/52. Policy HKPRU-2021-084421 inception Jan 2021. No pre-existing disclosures. Standard inpatient + surgical cover, max HK$1.5M p.a.
Claims History (24 months): 6 prior claims totalling HK$184,000 — 3 outpatient (routine), 2 inpatient (appendectomy 2023, knee arthroscopy Mar 2025). The Mar 2025 knee claim (HK$68,000) is the suspected duplicate of this submission.
Claims History (24 months): 6 prior claims totalling HK$184,000 — 3 outpatient (routine), 2 inpatient (appendectomy 2023, knee arthroscopy Mar 2025). The Mar 2025 knee claim (HK$68,000) is the suspected duplicate of this submission.
Claims (24M)
6
Total Paid
HK$184K
Watchlist
YES
Policy Status
ACTIVE
Assessor Decision
FWA Co-pilot
14:51
I've analysed CLM-25-091044. The primary concern is a confirmed duplicate billing pattern: procedure HX-441 was paid 42 days ago (CLM-25-074102). This matches confirmed case FWA-2024-00118 at 92% similarity.
My recommendation: Escalate to Fraud Investigation Unit and hold payment pending investigation.
My recommendation: Escalate to Fraud Investigation Unit and hold payment pending investigation.
FWA-2024-00118
RULE-INP-042
Prior claim
You
What is the P90 benchmark for HX-441 at Gleneagles HK?
FWA Co-pilot
Based on 2024 benchmark data for HX-441 (knee arthroscopy) at Gleneagles HK:
P50: HK$82,400 | P75: HK$94,800 | P90: HK$105,200
This claim (HK$138,000) is at approximately P97, well above clinical norms. The implant line item (HK$48,000) appears to be the primary driver of the excess.
P50: HK$82,400 | P75: HK$94,800 | P90: HK$105,200
This claim (HK$138,000) is at approximately P97, well above clinical norms. The implant line item (HK$48,000) appears to be the primary driver of the excess.
2024 Tariff Benchmarks
Gleneagles HK Data
You
What action did we take on similar cases in the FWA library?
FWA Co-pilot
In 3 similar duplicate billing cases from the FWA library:
• All 3 were escalated to Fraud Investigation Unit
• 2 of 3 resulted in full recovery (avg HK$67K)
• 1 resulted in policy cancellation
• Avg investigation duration: 11 days
Suggested next step: Escalate with reference to FWA-2024-00118.
• All 3 were escalated to Fraud Investigation Unit
• 2 of 3 resulted in full recovery (avg HK$67K)
• 1 resulted in policy cancellation
• Avg investigation duration: 11 days
Suggested next step: Escalate with reference to FWA-2024-00118.
FWA Library (3 cases)