Audit Performance Evaluation System for Claim Administrators
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Solution Overview
Problem
Insurance providers face challenges in objectively evaluating the performance of claim administrators due to subjective internal audits, which lack depth and insight into adherence to best practices, placing the burden on risk managers to assess performance effectively.
Innovation Solution
An audit performance evaluation system utilizing objective and specific measurable criteria, implemented with computing devices and networks, allows risk managers to assess claim administrators' performance against industry standards, facilitating the selection and management of claim administrators and potentially reducing claim costs.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If subjective internal audits are used to evaluate claim administrator performance, then the evaluation process is simple and quick, but the evaluation lacks objectivity, depth, and insight into adherence to best practices
Solution Approach 1:
The patent introduces an intermediary evaluation system that acts as a mediator between the risk manager and claim administrators. This system uses standardized audit protocols and objective criteria to assess performance, replacing subjective human judgment with structured, data-driven evaluation. The intermediary system processes audit data through defined methodologies to produce unbiased performance metrics.
Solution Approach 2:
The patent transforms the evaluation approach by changing key parameters from subjective to objective measurements. Performance is assessed using quantifiable metrics such as adherence to best practices, compliance with procedures, and measurable outcomes rather than subjective impressions. This parameter transformation enables precise, comparable, and reproducible evaluations across different claim administrators.
2Loss of information
If detailed objective evaluation criteria are implemented, then evaluation depth and insight improve, but the time and resources required for assessment increase
Solution Approach 1:
The patent implements preliminary action by establishing standardized audit protocols, evaluation criteria, and data collection templates before the actual assessment process. These pre-defined frameworks include checklists, performance indicators, and best practice benchmarks that guide the evaluation process. By preparing these tools in advance, the system enables comprehensive assessments to be conducted efficiently without ad-hoc delays.
Solution Approach 2:
The patent incorporates feedback mechanisms that provide claim administrators with detailed performance information based on objective criteria. The evaluation system collects data, analyzes it against established standards, and returns actionable feedback highlighting areas of compliance and non-compliance. This feedback loop enables continuous improvement while maintaining evaluation efficiency through automated data processing and standardized reporting.
Data Source
AI summary
Audit performance systems and methods can be used to provide objective assessment of the performance of claim administrators. Data from audits performed by one or more insurance broker consultants can be input into the audit performance system, and analyzed, to generate reports that compare the performance of a selected claim administrator to an industry standard level of performance or to one or more other claim administrators.