Decision Table Software Generator for Insurance Claims
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Solution Overview
Problem
Existing insurance claim processing software is complex and scattered, making it difficult to identify and define conditions for automatic denial or further review, especially for non-technical users, and is time-consuming to create and integrate new conditions.
Innovation Solution
A method and system that uses decision tables to automatically generate software for recognizing and flagging specific conditions in insurance claims, allowing for the creation of computer programming instructions that post edits based on defined conditions, enabling intuitive modification and integration of new conditions without requiring extensive programming expertise.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Extent of automation
If software is constructed to analyze factors and identify claims for automatic denial or review, then the ability to process insurance claims automatically is improved, but the complexity and scattered nature of the software makes it difficult to identify and modify conditions
Solution Approach 1:
The patent segments the complex software system into distinct modules: a decision table module that stores conditions and actions in a structured format, an evaluation module that processes claims against these conditions, and a separate configuration interface. This segmentation allows each module to be developed and modified independently, reducing overall system complexity while maintaining automation capabilities.
Solution Approach 2:
The patent introduces a decision table as an intermediary layer between the claim data and the processing logic. This decision table serves as a mediator that stores conditions, actions, and thresholds in a standardized format, allowing business rules to be defined and modified without changing the underlying software code, thus reducing complexity while preserving automated processing.
2Measurement precision
If software code is used to define conditions for denying benefits or flagging claims, then automated evaluation capability is improved, but non-technical users find it challenging to determine and modify conditions
Solution Approach 1:
The decision table acts as an intermediary that translates complex software logic into a user-friendly tabular format. Non-technical users can view, add, modify, and delete conditions by simply editing the decision table entries rather than writing or understanding code, making precise condition evaluation accessible to business users without programming expertise.
Solution Approach 2:
The patent creates a simplified copy or representation of the software's decision-making logic in the form of a decision table. This tabular copy mirrors the actual processing conditions but presents them in an accessible format that non-technical users can easily understand and modify, bridging the gap between precise evaluation requirements and user accessibility.
3Adaptability or versatility
If new software is created to define new conditions for denying benefits or flagging claims, then the adaptability of the system is improved, but the time-consuming process of creating and integrating new software reduces productivity
Solution Approach 1:
The patent implements a dynamic decision table that can be modified at runtime without requiring software recompilation or reintegration. New conditions, actions, and thresholds can be added or changed by updating the decision table structure, allowing the system to adapt to new requirements instantly, thereby maintaining high adaptability while eliminating the time-consuming software integration process.
Solution Approach 2:
The patent establishes a pre-configured decision table framework with standardized structures for conditions, actions, and thresholds before actual use. This preliminary setup includes predefined templates and validation rules that guide users in adding new conditions, eliminating the need to create software structures from scratch and significantly accelerating the adaptation process while maintaining system integrity.
Data Source
AI summary
A method, system and computer program product are provided for creating software that can be used when processing insurance claims. In particular, the software generated is capable of recognizing and flagging certain situations or sets of conditions when they arise in an insurance claim that is being processed. These situations or sets of conditions, as well as the type of flag, or “edit,” that should be posted when each occurs, are defined in a decision table from which the software is automatically generated. A method of processing an insurance claim using the automatically generated software is also provided.