Dynamic Topological Claims Processing System for Denial Prediction
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Solution Overview
Problem
Current healthcare claims processing systems are inefficient, leading to high administrative costs and inaccuracies, with 1 in 5 claims being processed incorrectly, resulting in significant financial losses due to waste, fraud, and abuse, and lacking the ability to predict claim denials effectively.
Innovation Solution
A dynamic topological system and method for claims processing that uses a feature matrix converter, mapper component, and classification component to determine a claim denial score by segmenting claims datasets into local neighborhoods and training classifiers for each neighborhood, allowing for accurate prediction of claim denials and reducing errors.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If legacy systems are used for claims processing, then existing infrastructure is maintained, but processing accuracy deteriorates with 1 in 5 claims being processed incorrectly
Solution Approach 1:
The patent segments the claims processing system into multiple specialized components: a feature matrix converter that transforms claims data into structured features, a mapper component that organizes features into neighborhoods, and a classification component that applies specialized classifiers to different claim types. This segmentation allows each component to optimize for its specific function, improving overall processing accuracy while managing complexity through modular architecture.
2Productivity
If traditional claims processing methods are used, then current operational procedures are maintained, but administrative costs increase to upwards of $210 billion per year
Solution Approach 1:
The patent applies preliminary action by performing feature extraction, data transformation, and predictive classification before final claims adjudication. The system pre-processes claims data through the feature matrix converter and mapper to identify patterns and predict outcomes in advance, allowing for early intervention and correction of problematic claims before they reach traditional processing stages, thereby reducing rework and administrative costs.
3Speed
If dynamic transactional data streaming is implemented, then real-time processing capabilities are enhanced, but system complexity increases
Solution Approach 1:
The patent introduces intermediary components that facilitate real-time data streaming: the feature matrix converter acts as an intermediary that continuously transforms incoming claims data into standardized feature representations, while the mapper component serves as another intermediary that organizes these features into neighborhood structures. These intermediaries enable real-time processing by creating structured intermediate representations that can be quickly classified without requiring complex end-to-end system redesign.
Data Source
AI summary
A dynamic topological system and method for efficient claims processing are provided. The dynamic topological system and method for efficient claims processing may be used in a healthcare system. The dynamic topological system and method for efficient claims processing is easily extensible, maintainable and extendable.