Pakistan, Oct. 3 -- A model that decides which hospital gets investigated is exercising public power. It may be accurate, fast and cheap; none of that is the same as being authorised. Every technical question about claims analytics collapses eventually into three questions of governance: who may build the model, who audits it, and what a hospital can do on the day the number is wrong.

America answered part of this in February 2026, when the Office of Inspector General at Health and Human Services issued new compliance guidance for the Medicare Advantage programme - its first substantial revision since 1999. Payers are advised to run outlier detection, apply filtering logic to identify anomalies, and benchmark coding intensity across prov...