Claims Processing Rules Using Decision Tables
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Solution Overview
Problem
Current claims processing systems are inefficient and costly due to the complexity of updating and changing multi-line claim rules, which require significant time and resources to enforce dynamic medical policies, payment policies, and contract terms.
Innovation Solution
A data-driven approach is implemented using tables such as the COMPARE_DECISIONS, COMPARE_EXCLUSIONS, and COMPARE_INCLUSIONS tables to determine how to process claim lines based on specific rules, allowing for efficient updates and changes to claims processing rules by referencing these tables during the processing of current and support claim lines.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If traditional multi-line claim rules are used to enforce dynamic medical policies and payment policies, then claims processing can be performed, but updating and changing the rules requires significant time, effort, and expense
Solution Approach 1:
The patent segments the claims processing rules into modular components organized in a decision tree structure. Each node in the decision tree represents a specific rule or decision point that can be independently configured and updated. This segmentation allows individual rule changes without requiring comprehensive system reconfiguration, thereby reducing update time and effort while maintaining adaptability.
Solution Approach 2:
The patent implements dynamic rule configuration through a flexible decision tree structure that can be modified in response to changing medical policies and payment policies. The system allows runtime adjustments to rule parameters and decision logic without requiring system downtime or extensive reprogramming, enabling rapid adaptation to new requirements while minimizing update time.
2Adaptability or versatility
If traditional multi-line claim rules are used to enforce dynamic medical policies and payment policies, then claims processing can be performed, but the system requires significant resources for maintenance and updates
Solution Approach 1:
The patent divides the complex claims processing system into discrete, manageable decision nodes arranged in a tree structure. Each node encapsulates a specific rule or decision criterion, making the overall system complexity tractable. This modular architecture reduces maintenance resources by isolating rule logic into independent units that can be developed, tested, and updated separately.
Solution Approach 2:
The decision tree structure serves multiple functions simultaneously: it enforces medical policies, applies payment policies, validates claim data, and generates processing decisions. This multi-functionality reduces the need for separate rule engines and validation systems, thereby reducing overall system complexity and resource requirements while maintaining high adaptability to different policy requirements.
Data Source
AI summary
Systems, methods, apparatus, and computer program products are provided for processing claims. In various embodiments, claims can be processed in accordance with a data-driven approach that limits changes to existing claims processing rules by using an inclusions table, an exclusions table, and/or a decision table as part of firing or executing claims processing rules to accommodate for such changes.