MUMBAI, India, March 13 -- Intellectual Property India has published a patent application (202611009534 A) filed by Chirag Goyal, Jaipur, Rajasthan, on Jan. 30, for 'an ai driven scheme aware medical admissibility and fraud analysis system for healthcare insurance claims and method of performing the same.'
Inventor(s) include Chirag Goyal.
The application for the patent was published on March 13, under issue no. 11/2026.
According to the abstract released by the Intellectual Property India: "The present invention relates to an AI driven, scheme aware medical admissibility and fraud analysis system and method for healthcare insurance claims is disclosed. the system receives heterogeneous claim information including patient and beneficiary identifiers, encounter and treatment details, procedure packages with associated codes, rates and quantities, diagnoses, performed procedures, supporting medical documents, and clinical or visual evidences, and structures the information into a unified internal representation without altering underlying medical facts. artificial intelligence models analyse procedure packages for semantic alignment with diagnoses, internal consistency of package combinations, and reasonableness of declared rates and quantities, and classify each package with an explainable admissibility outcome. clinical AI models evaluate medical appropriateness of procedures for stated diagnoses, coherence among multiple procedures, and alignment with observed care pathways, generating confidence scored and human interpretable reasoning. documentation and evidence are correlated with diagnoses and procedures to determine sufficiency despite variations in format or terminology. outputs of package admissibility, medical appropriateness, and evidence sufficiency analyses are consolidated into a comprehensive medical admissibility assessment using configurable, scheme or client specific weighting. a scheme aware fraud analysis module applies identity consistency checks, transaction and authorization coherence analysis, behavioural pattern analysis, and anomalous utilization detection in the context of government or private insurance schemes. the system generates a structured, auditable and machine consumable claim intelligence output providing explainable medical admissibility and fraud risk assessments, usable across multiple claim processing workflows without autonomously determining claim approval or payment outcomes."
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