RISK & SOLVENCY OPTIMISER
Stop FWA leakage
before the scheme
ever sees the claim.
QR-E is a pre-adjudication validation engine that intercepts unbundled, inflated, and non-compliant medical claims at the gate – eliminating the need for expensive, hostile, retrospective forensic audits.
ANNUAL FWA LEAKAGE
Fraud, waste and abuse in SA private healthcare annually
R28B
DEMONSTRATED ROI
Return per rand spent on QR-E licensing
5:1
INTEGRATION MODEL
API-first. Connect without changing your infrastructure
API
COMMERCIAL RISK
You only pay on what QR-E catches. Zero upfront exposure.
Zero
Pre-Adjudication
Claims intercepted before the scheme processes them
API-First
Integrates with your existing switch or claims system
Performance-Linked
Shared savings model – you pay only on intercepted leakage
THE PROBLEM
The audit is too late.
The damage is
already done.
Medical schemes currently absorb inflated claims, recover costs through premium increases, and pursue overcharging through retrospective forensic audits. This process is expensive, adversarial, legally complex, and rarely recovers full value.
Traditional switches look at data syntax. QR-E looks at clinical intent.
01
Unbundling is invisible to existing systems
Medical switches validate that individual codes are compliant. They do not detect when a combination of codes constitutes an unbundled infringement — billing separately for components already included in a procedure’s tariff.
02
Retrospective audits are costly and hostile
Forensic audit processes are expensive, slow, and damage provider relationships. Recovery rates are partial. The legal exposure is significant. And by the time the audit identifies the problem, millions have already been paid out.
03
Members absorb the cost through premiums
Schemes recover inflated claim costs through annual premium increases above CPI. The structural leakage is passed directly to members — who have no visibility and no recourse.
HOW QR-E WORKS
Three layers.
One clean claim.
QR-E sits between the provider and the scheme as a neutral API layer. Claims are validated against contracted scheme tariffs and clinical bundling rules before adjudication. Non-compliant claims are returned to the provider for revision. The scheme only receives claims that have cleared all three compliance layers.
PROVIDER
SUBMITS CLAIM
QR-E
VALIDATES ALL 3 LAYERS
CLEAN CLAIM
IF COMPLIANT
SCHEME
RECEIVES ONLY CLEAN CLAIMS
01
Per-Line Tariff Check
Every procedure code is benchmarked against the scheme’s contracted rate schedule. Items billed above the contracted threshold are flagged before the scheme ever sees the claim.
02
Bundling & Modifier Rules
Facility and equipment modifier codes are disallowed alongside procedures that already include them in their tariff. Modifier stacking and unbundling are caught automatically using set intersection logic.
03
ICD-10 Cluster Cap
All line items sharing a diagnosis code are summed. Individually-valid items are flagged if the cluster total exceeds the contracted composite rate for that diagnosis group.
LIVE VALIDATION EXAMPLE
One colonoscopy.
R4,720 in excess.
Blocked at the gate.
The provider billed R12,220. The contracted composite rate is R7,500. QR-E identified three bundling violations and returned the claim to the provider before the scheme saw it.
Procedure 1653 (total colonoscopy) includes facility, monitoring, and equipment charges in its contracted tariff. Billing codes 0004, 0007, and 0074 separately constitutes unbundling — each appearing individually legitimate, together representing a R4,720 overcharge.
QR-E’s flat code set matrix detects this pattern in a single set intersection operation. No manual review. No audit. No dispute. The claim is returned to the provider automatically.
COMMERCIAL MODEL
A self-funding compliance gateway with guaranteed net-positive return.
QR-E eliminates pre-adjudication leakage by intercepting non-compliant, unbundled, and incorrect claims in real time. Our commercial structure is engineered to be net-positive from Day 1, paying for itself through prevented leakage during launch and transitioning into a high-efficiency processing infrastructure at scale.
SINGLE TRANSACTION ILLUSTRATION
Claim submitted
R12,220
QR-E intercepts excess
-R4,720
Scheme pays out
R7,500
QR-E fee (10%)
-R472
Scheme net saving
R4,248
LAUNCH AND VALIDATION
Shared Savings
10-15%
OF INTERCEPTED LEAKAGE
- Zero Budget Allocation – Fully funded out of immediate recovered leakage
- Instant Proof of Value – Establishes scheme-specific baseline within 90 days
- Zero Financial Downside – Fees are strictly contingent on verified blocked leakage
SCALE AND PRODUCTION
Tiered Processing
R0.95 – R2.50
PER CLAIM PROCESSED
- Predictable Costing – Volume-discounted pricing as integration deepens
- 100% Pre-Clearing – Covers all incoming submissions prior to adjudication
- Operational Efficiency – Replaces costly post-payment forensic audits
MATURE GATEWAY
Blended Solvency Target
R1.00 + 2.5%
FLAT FEE + PERFORMANCE KICKER
- Sustainable Protection – Blends baseline infrastructure support with downside protection
- Behavioural Alignment – Maintains active engine monitoring as submission compliance nears 100%
INTEGRATION
Come as you are.
No IT backlog required.
QR-E adopts a “come as you are” data policy. Your existing claims format — whether Healthbridge, MediSwitch, GoodX, or a proprietary legacy structure — is accepted and normalised internally. Your IT team does not need to refactor a single pipeline.
Once connected, the integration is permanent. QR-E handles format changes, tariff schedule updates, and regulatory amendments as standard. Your team maintains nothing.
POST /v1/validate // Submit claim for validation
GET /v1/rules/:code // Query bundling rules
GET /v1/health // Engine status
SUPPORTED FORMATS
HEALTHBRIDGE
Native format adapter – full field mapping
LIVE
QR-E NATIVE
Flat JSON — recommended for new integrations
LIVE
GENERIC
Best-effort extraction from any JSON payload
LIVE
MEDISWITCH
Native format adapter
IN DEVELOPMENT
GOODX
Native format adapter
IN DEVELOPMENT
HL7 FHIR R4
For modern clinical systems
IN DEVELOPMENT
GET THE FULL PICTURE
The claim is already
being submitted.
Download the QR-E pitch deck for the full investment case, technical architecture, and go-to-market roadmap. Or request a direct briefing with the Infimetrica team.
Send download link to:
No marketing emails. One email with the deck link. That’s it.
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INFIMETRICA
QR-E RISK & SOLVENCY OPTIMISER
Enterprise solutions for high-liability industries. API-first. Performance-linked. Production-grade.
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