Domain-Specific Rule Compiler for Automated Claim Validation
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Solution Overview
Problem
Processing claims to detect fraud, abuse, and waste (FWA) is a complex and cumbersome process, especially in domains like healthcare, requiring detailed clinical analysis and domain-specific rules that are difficult for humans to configure and share, leading to repetitive work and inefficiencies.
Innovation Solution
A system and method for creating and converting domain-specific rules from a domain-specific language to a general programming language, allowing for automated validation of claims across a network, facilitating interoperability and reducing manual configuration efforts.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If domain specific rules are manually configured by SMEs, then validation accuracy is improved, but device complexity and ease of operation deteriorate
Solution Approach 1:
The patent introduces an intermediary system that includes a domain specific language compiler and rule templates. This intermediary automatically translates natural language or high-level domain rules into executable validation logic, eliminating the need for SMEs to manually configure complex rules while maintaining validation accuracy through automated compilation and interpretation.
Solution Approach 2:
The system enables self-service by allowing the automated system to generate, validate, and deploy domain specific rules without requiring manual intervention from SMEs. The rule templates and automatic compilation mechanisms allow the system to serve itself in configuring validation rules, reducing complexity while maintaining reliability through consistent automated processing.
2Reliability
If domain specific rules are manually configured by SMEs, then validation accuracy is improved, but productivity deteriorates
Solution Approach 1:
The system performs preliminary action by pre-defining rule templates and compilation structures that are ready for automated instantiation. When claims need validation, the system can quickly instantiate and apply pre-compiled rules without requiring manual configuration at the time of processing, thereby maintaining high validation accuracy while dramatically improving processing speed and productivity.
Solution Approach 2:
The patent replaces the mechanical manual configuration process with an automated computational system. The domain specific language compiler and rule template engine automatically generate validation logic, substituting manual SME efforts with automated processing that maintains accuracy while increasing productivity through consistent, rapid rule application across large volumes of claims.
3Reliability
If domain specific rules are manually configured, then rule effectiveness is improved, but loss of time deteriorates
Solution Approach 1:
The system uses copying by allowing rule templates to be replicated and instantiated multiple times across different validation scenarios. Instead of manually configuring rules each time, the system copies and adapts pre-defined templates through automated compilation, maintaining rule effectiveness while reducing configuration time from hours or days to minutes or seconds.
4Reliability
If manual domain specific rule configuration is used, then expertise utilization is improved, but ease of operation deteriorates
Solution Approach 1:
The intermediary compilation system acts as a bridge that captures expert knowledge in domain specific rules and translates it into automated validation logic. SMEs can express rules in natural or domain-specific language without needing to understand the underlying complexity, and the compiler mediates by transforming these expressions into effective validation rules, maintaining expertise utilization while dramatically improving ease of operation.
Data Source
AI summary
Systems and method for processing domain specific claims is disclosed. The system comprises a memory, a processor, and a network interface communicatively coupled to the processor and the memory. The memory comprises computer instructions that when executed by the processor cause the system to perform functions. The functions comprise creating domain specific rules in a domain specific language based on domain specific regulations. The functions also comprise converting the created domain specific rules from the domain specific language to a target programming language. Further, the functions comprise accessing the domain specific claims via the network interface or a storage unit. Furthermore, the functions comprise validating the domain specific claims based on the converted domain specific rules respectively. In addition, the functions comprise providing a validation result corresponding to the domain specific claims respectively based on the validation. The method comprises the functions performed by the system(s).