S/N 9 – FWA Performance Dashboard

HK$18.4M

+22% vs 2024 YTD

142

+18% vs 2024 YTD

4.82%

+0.9pp vs 2024 YTD

2,946

Of 61,204 total claims

73.4%

+5.1pp Agent-driven

11.2

-3.4d vs prior year

Monthly FWA Savings & Confirmed Cases (YTD)

Savings

Cases

FWA Type Breakdown

Fraud74 cases · HK$9.8M

Waste46 cases · HK$6.1M

Abuse22 cases · HK$2.5M

FWA Outcomes at L3 Taxonomy Level

Drill-down from portfolio KPI to claim-level root cause

FR

Billing

Duplicate Procedure

34

HK$4.8M

5.6%

+12%

WA

Inpatient

Excessive LOS

28

HK$3.2M

4.6%

+8%

FR

Provider

Ghost Provider

19

HK$2.9M

3.1%

-4%

WA

Billing

Room Upcoding

17

HK$1.8M

2.8%

-7%

AB

Outpatient

TCM Overbilling

14

HK$1.1M

2.3%

-11%

FR

Eligibility

Pre-existing Concealment

12

HK$0.9M

2.0%

+3%

AB

Inpatient

Unnecessary Admission

10

HK$0.8M

1.6%

-5%

WA

Billing

Unbundling Procedures

8

HK$0.6M

1.3%

+6%

Showing 8 of 24 L3 categories

Remediation Actions (Open)

Gleneagles HK — Enhanced Monitoring

34 confirmed cases YTD. Provider meeting scheduled 15 Jun. Pre-auth required for all surgical claims > HK$50K.

OPEN

Rule RULE-INP-042 — Reduce Threshold

Duplicate window extended from 60→90 days based on YTD pattern analysis. Pending approval.

PENDING

TCM Overbilling — New Rule Deployed

RULE-TCM-017 deployed May 2025. Detection rate +11% in June. Case count trending down.

CLOSED

AI Insights & Recommendations

Duplicate Billing — Rising Trend

Duplicate procedure billing increased 12% YTD, concentrated at 2 providers. Recommend tightening duplicate window to 90 days and adding post-pay audit cycle for these providers.

Ghost Provider Network Declining

Ghost provider cases down 4% following RULE-PROV-009 deployment. Estimated HK$2.9M protected. Continue enhanced onboarding verification for new providers.

Pre-existing Concealment — Emerging Pattern

3% uptick in pre-existing concealment cases at policy ages 0–12 months. Recommend ML model refresh targeting early-claim, high-complexity cases.

Monthly Savings vs Avoidance (YTD)

Confirmed Recovery

Avoidance

Savings Breakdown

HK$12.1M

Payment clawback · 142 cases

HK$6.3M

Rejected / held before payment

78%

HK$130K

Savings by L3 Category (Top 8)

Duplicate Procedure

HK$4.8M

34

HK$141K

+12%

Excess LOS

HK$3.2M

28

HK$114K

+8%

Ghost Provider

HK$2.9M

19

HK$153K

-4%

FWA Taxonomy — Full L3 Drilldown

Click any row to see contributing claims and root cause breakdown

Root Cause by Detection Method

Top Root Causes

Provider billing manipulation38%

Claimant-provider collusion24%

Policy non-disclosure18%

Coding upcoding / unbundling12%

Unnecessary treatment8%

Detection Method Effectiveness

Rules Engine

88

91.4%

88.7%

HK$11.2M

ML Models

64

88.2%

84.1%

HK$4.8M

LLM / Doc AI

31

92.8%

90.1%

HK$1.8M

Human (QA)

21

—

HK$0.6M

8

Require attention

5

Awaiting sign-off

24

↑ 6 vs prior year

All Remediation Actions

Gleneagles HK Enhanced Monitoring

Risk Team

15 Jun

HK$4.8M

OPEN

RULE-INP-042 Threshold Update

Rules Team

20 Jun

Est. +15 cases

PENDING

Pre-existing ML Model Refresh

Data Science

30 Jun

Est. +8 cases

PENDING

TCM RULE-TCM-017 Deployment

Rules Team

Done

HK$1.1M

CLOSED

Ghost Provider Onboarding Check

Compliance

Done

HK$2.9M

CLOSED

Provider Watchlist Review (Q2)

Fraud Inv.

Overdue

—

OPEN