Benefit Plan QA Dashboard for Claims Adjudication Certification
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Solution Overview
Problem
Current benefit management systems face challenges such as high costs, manual error-prone processes, lack of end-to-end traceability, and difficulty in accurately reflecting client intent, leading to inefficiencies and inaccuracies in managing and certifying benefit plans.
Innovation Solution
An interactive dashboard and automated system for generating and assembling benefit components and rules, providing end-to-end traceability, and enabling automated quality assurance and certification testing to ensure accurate reflection of user intent and minimize errors.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Ease of operation
If manual techniques (spreadsheets, emails, handwritten notes) are used to capture and manage benefits, then flexibility in benefit plan management is maintained, but error rates increase and audit readiness deteriorates
Solution Approach 1:
The patent replaces manual mechanical processes (spreadsheets, emails, handwritten notes) with an automated computer-based system that electronically captures, stores, and processes benefit plan data. This substitution eliminates manual errors while maintaining operational flexibility through the user interface that allows configuration of benefit plans according to client requirements.
Solution Approach 2:
The system enables automated self-service capabilities where the benefit management system automatically tracks, monitors, and manages benefit plan components without requiring manual intervention. The system self-updates records, self-generates audit trails, and self-maintains data integrity, reducing errors while preserving ease of operation through automated workflows.
2Device complexity
If traditional manual methods are used for benefit plan management, then system simplicity is maintained, but traceability and audit capability are lost
Solution Approach 1:
The system implements automated feedback mechanisms that continuously track and record all benefit plan management activities. Every action, modification, and decision is automatically logged with timestamps, user identifiers, and contextual information, creating a complete audit trail that maintains traceability without adding perceived complexity to the user interface.
Solution Approach 2:
The patent introduces an intermediary automated system layer between users and the benefit plan data. This intermediary automatically captures, stores, and manages all interactions with benefit plans, preserving traceability and audit information while presenting a simple interface to users. The intermediary handles the complexity of tracking and reporting automatically.
3Adaptability or versatility
If benefit plan components are managed with disparate systems, then adaptability to different benefit structures is maintained, but integration understanding and cross-dependency tracking are lost
Solution Approach 1:
The patent implements a universal benefit plan management system that can handle various benefit plan structures through a single integrated platform. The system uses configurable templates and parameters that adapt to different benefit types (medical, pharmaceutical, dental) while maintaining a unified data model that automatically tracks cross-dependencies among all components regardless of the specific benefit structure being managed.
Solution Approach 2:
The system employs a nested hierarchical structure where benefit plans contain groups, which contain benefit components, which contain specific parameters. This nested organization allows the system to manage various benefit structures at different levels of granularity while automatically tracking relationships and dependencies across all nested levels, preserving integration understanding without sacrificing adaptability.
4Measurement precision
If quality assurance testing is performed manually on benefit plans, then testing thoroughness can be maintained for small volumes, but productivity and time efficiency deteriorate as claim volumes increase
Solution Approach 1:
The patent replaces manual quality assurance testing with automated computer-based testing systems that execute test cases, validate benefit plan configurations, and verify claims adjudication accuracy. This substitution maintains thoroughness by systematically testing all required scenarios while dramatically increasing productivity through automated execution of numerous test cases simultaneously, enabling efficient validation of large claim volumes.
Data Source
AI summary
A system for testing a benefit plan for quality assurance is provided. A test adjudication engine is configured to process claims in accordance with the benefit plan, each of the claims having one or more parameters. A database is configured to store the benefit plan and quality assurance data, the quality assurance data including: (a) historical claims, each historical claim having an associated historical adjudication, and (b) new claims, each new claim not having an associated historical adjudication. An interactive dashboard is configured to allow a user to batch claims for processing by the test adjudication engine, from among the historical claims and the new claims, based on the one or more parameters.