Healthcare Claims Decision Support System for Error Reduction
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Solution Overview
Problem
Healthcare claims processing is inefficient and error-prone, with significant administrative costs and inaccuracies due to issues like excessive procedure charges, insufficient diagnosis codes, and invalid procedure combinations, leading to waste, fraud, and abuse, with no existing system providing adequate support for identifying and addressing these issues during adjudication.
Innovation Solution
A healthcare claim decision support system utilizing X12 APIs, which includes an API processor, identity matcher, and claims processing engine to perform sliding window analysis, frequent item set analysis, and procedure code co-occurrence analysis, generating user interfaces to alert users to potential errors and suggest corrections before claims are submitted for adjudication.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If manual claims processing is performed without automated decision support, then processing flexibility is maintained, but processing accuracy and efficiency deteriorate due to human error and high administrative costs
Solution Approach 1:
The patent introduces an intermediary decision support system that acts as a mediator between claims processors and claims adjudication. This system provides automated analysis, flags potential issues, and suggests resolutions, thereby improving both efficiency and accuracy without completely replacing human processors. The intermediary system handles the analytical workload while human processors focus on final decision-making.
Solution Approach 2:
The patent replaces manual mechanical processing with automated computer-based analysis systems. The system uses automated algorithms to analyze claims data, identify patterns, detect potential fraud, and generate recommendations, substituting the mechanical human processing workflow with an automated electronic system that operates faster and with greater consistency.
2Reliability
If comprehensive claims analysis is performed to identify all potential errors, then claims accuracy is improved, but processing time and complexity increase
Solution Approach 1:
The patent applies preliminary action by performing automated preliminary analysis of claims before they reach final adjudication. The system pre-identifies potential issues, validates data completeness, checks for obvious errors, and prepares analysis results in advance. This preliminary screening reduces the time needed for final review while maintaining comprehensive accuracy checks.
Solution Approach 2:
The patent implements partial action by focusing analysis efforts on the most critical and high-risk areas of claims processing. Rather than uniformly analyzing every aspect of every claim with equal depth, the system applies more rigorous analysis to high-value or high-risk claims while using streamlined analysis for lower-risk claims, optimizing the balance between accuracy and processing time.
3Measurement precision
If detailed analysis of procedure codes and diagnosis codes is performed, then detection precision of abnormal claims is improved, but device complexity increases
Solution Approach 1:
The patent applies segmentation by dividing the complex claims analysis into distinct modular components: procedure code validation, diagnosis code validation, medical necessity verification, fraud detection, and utilization review. Each module handles a specific aspect of analysis independently, making the overall complex system manageable through functional decomposition and allowing parallel processing of different analysis tasks.
Data Source
AI summary
A healthcare claims processing and decision support system and method are disclosed that allow for the pre-processing of the healthcare claims as well as a method to reduce much of this overhead and alerting the user to any errors that occur during the claims processing.