The provider network as entities, not claims: who bills, how much, how often they are denied, and what share of billed value is actually allowed. Entity-level patterns are the ones a single claim can never reveal.
Billed versus allowed across the empanelled network — the gap is the negotiation and leakage surface.
Each provider compared to peers on average billed per claim, denial rate, allowed ratio and volume concentration. High scores are candidates for audit or de-empanelment review, not accusations.
| Provider | Specialty | Claims | Avg billed | Denied | Allowed | Score | Why |
|---|---|---|---|---|---|---|---|
| Dr. Vishal Rao | Pediatrics | 34 | ₹70,487 | 35.3% | 63.8% | 0.47Medium | Elevated denial rate +0.22 |
| Dr. Meena Das | General Medicine | 27 | ₹62,811 | 29.6% | 64.3% | 0.47Medium | Elevated denial rate +0.22 |
| Dr. Priya Rathore | Cardiology | 23 | ₹72,323 | 34.8% | 57.5% | 0.47Medium | Elevated denial rate +0.22 |
| Dr. Girish Verma | Emergency | 30 | ₹54,447 | 43.3% | 66% | 0.47Medium | Elevated denial rate +0.22 |
| Dr. Ravi Kulkarni | Emergency | 24 | ₹65,608 | 33.3% | 61% | 0.47Medium | Elevated denial rate +0.22 |
| Dr. Mukesh Kapoor | Emergency | 27 | ₹58,252 | 29.6% | 60.2% | 0.47Medium | Elevated denial rate +0.22 |
| Dr. Neha Sharma | Cardiology | 25 | ₹62,600 | 32% | 61.9% | 0.47Medium | Elevated denial rate +0.22 |
| Dr. Smita Pillai | General Medicine | 25 | ₹62,579 | 32% | 57.5% | 0.47Medium | Elevated denial rate +0.22 |
| Dr. Harish Bansal | General Medicine | 42 | ₹62,317 | 21.4% | 58.1% | 0.35Low | High volume +0.10 |
| Dr. Vishal Singh | Radiology | 38 | ₹68,148 | 21.1% | 59.9% | 0.25Low | no features triggered |
| Dr. Suresh Tripathi | Oncology | 40 | ₹62,217 | 15% | 59.4% | 0.25Low | no features triggered |
| Dr. Vikas Mehta | Oncology | 31 | ₹77,284 | 25.8% | 56.7% | 0.25Low | no features triggered |
| Dr. Ramesh Trivedi | General Medicine | 39 | ₹61,399 | 10.3% | 61.7% | 0.25Low | no features triggered |
| Dr. Shalini Sethi | Cardiology | 34 | ₹67,409 | 20.6% | 61.2% | 0.25Low | no features triggered |
Live rows: 120 health claim records read from demo_health.provider + insurance_claim in PostgreSQL at request time. These are genuine records with genuine structure, but they are synthetic demo data, not Generali Central's book — status distributions are near-uniform, and person, provider, branch and payer names are localised to Indian display names at read time. Scores demonstrate the scoring mechanism, not predictive performance. The reconciled ₹5,548 Cr figures elsewhere in this cockpit come from the governed SQLite book.
For each submitted claim: billed amount against the specialty average, the payer's allowed ratio and historical pay ratio, and whether the encounter was an emergency. Approval likelihood is one minus the denial score.
| Provider | Specialty | Encounter | Billed | Payer | Approval | Why |
|---|---|---|---|---|---|---|
| Dr. Naveen Iyengar | Neurology | OUTPATIENT | ₹119580.22 | Kavach Health Assurance | 47% | Payer allows under half +0.20Non-admission encounter +0.08 |
| Dr. Kunal Pillai | Oncology | TELEHEALTH | ₹118782.29 | Kavach Health Assurance | 47% | Payer allows under half +0.20Non-admission encounter +0.08 |
| Dr. Priya Rathore | Cardiology | OUTPATIENT | ₹118662.37 | AayuCare Health Services | 47% | Payer allows under half +0.20Non-admission encounter +0.08 |
| Dr. Rohan Reddy | Pediatrics | OUTPATIENT | ₹117695.06 | Kavach Health Assurance | 47% | Payer allows under half +0.20Non-admission encounter +0.08 |
| Dr. Gayatri Mehta | Oncology | OUTPATIENT | ₹116888.87 | Suraksha MediCare TPA | 47% | Payer allows under half +0.20Non-admission encounter +0.08 |
| Dr. Mukesh Das | Oncology | OUTPATIENT | ₹115735.36 | SehatPlus TPA | 47% | Payer allows under half +0.20Non-admission encounter +0.08 |
| Dr. Anil Naidu | General Medicine | INPATIENT | ₹119493.14 | Swasth Bharat Assurance | 55% | Payer allows under half +0.20 |
| Dr. Vishal Singh | Radiology | INPATIENT | ₹119364.63 | SehatPlus TPA | 55% | Payer allows under half +0.20 |
| Dr. Satish Mehta | General Medicine | OUTPATIENT | ₹119765.18 | Jeevan Raksha Health Services | 67% | Non-admission encounter +0.08 |
| Dr. Aditya Yadav | Cardiology | TELEHEALTH | ₹118912.01 | Nirog Seva Health TPA | 67% | Non-admission encounter +0.08 |
Who settles, and what proportion of billed value they actually pay.