Reimbursement risk signals

Score a reimbursement file on eleven stated signals, each with its points and evidence, to decide how closely a desk should look. Signals for review, not findings.

The question it answers

Which reimbursement files deserve a closer look first?

You give it: The claim facts and every invoice: vendor, GSTIN, number, date, amount.

You get: A score from 0 to 100, the signals behind it with the invoices that raised them, and a suggested route.

The idea

Eleven stated signals add up to a score that suggests how closely a reimbursement file should be looked at.

Rules that run, in order

1. Consecutive invoice numbers across dates (+35)
2. A GSTIN that fails its own check (+25)
3. A provider on a watchlist (+20)
4. A cluster of admissions from one PIN code (+15)
5. Seven more signals, each with stated points

How well the rules are sourced

The GSTIN structure test is Secondary. The points and the two cut-offs are Draft: the author accepted them as close enough to keep but has not confirmed them one by one.

What it does not do

It raises risk signals for review, never a finding about a person or business. A well-formed GSTIN can still be cancelled or unissued, which it cannot know.

Steps

1. Enter the claim and its invoices. Dates of stay, the amount claimed, and each invoice. Add whether the provider is on a watchlist and how many similar admissions came from the same PIN code.
2. Eleven checks run. Consecutive invoice numbers across dates, a GSTIN that fails its own check character or is missing, a lab report with no qualified signatory, a bill outside the stay window, duplicates, a claim above the invoices, a long stay, a watchlisted provider, a PIN-code cluster, and round amounts.
3. Each signal adds stated points. The points are set out in the rules table. Each signal names the invoices that raised it, so nothing is a black box.
4. The total is compared with two cut-offs. Below 30, standard processing. From 30, a desk query. From 60, refer for field verification. No single signal can reach the top band alone.
5. Next steps and the PDF. The page lists suggested actions and every check that ran, including those that did not fire. The points and cut-offs are draft assumptions and are labelled that way.

Every case on this site is synthetic. These are working drafts and illustrations, not a claim decision or legal advice. The interactive worksheets need JavaScript; nothing is sent anywhere.