Mock Claim System for Accurate Payment Estimation
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Solution Overview
Problem
There is a significant lag between service provision and payment for healthcare providers, resulting in accounting complexities and increased administrative costs due to inaccuracies in estimated accounts receivable (A/R) when dealing with multiple payers and contracts.
Innovation Solution
A process that generates a mock claim using partial data, applying unique pricing rules specific to each payer's agreement to estimate payments before actual services are rendered, allowing for more accurate A/R management and reducing discrepancies.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If traditional claim processing is used, then actual payment accuracy is maintained, but the lag time between service provision and payment increases significantly
Solution Approach 1:
The system generates mock claims and applies pricing rules in advance to estimate payments before actual claims are processed. This preliminary action provides payment estimates during the service provision period, reducing the informational lag without compromising the accuracy of actual payment processing.
2Measurement precision
If traditional A/R estimation methods are used, then administrative processes are simpler, but estimation accuracy decreases significantly
Solution Approach 1:
The system creates mock claims that replicate the structure and format of actual claims. These copies allow the system to apply pricing rules and generate accurate payment estimates without processing real claims, thereby improving estimation accuracy while maintaining manageable system complexity through simulated rather than actual claim processing.
Solution Approach 2:
The mock claim serves as an intermediary between partial coding data and final payment estimation. By introducing this intermediate representation, the system can apply pricing rules to estimated data structures without requiring complete actual claim information, improving accuracy while keeping the process complexity controlled.
3Measurement precision
If mock claims are generated with partial data, then A/R estimation accuracy improves, but data completeness requirements increase
Solution Approach 1:
The system performs partial claim processing by generating mock claims with available coding data without requiring complete claim information. This partial action allows payment estimation to proceed with incomplete data, improving the timeliness and accuracy of estimates while accepting that not all claim details are yet known.
Data Source
AI summary
Processes for estimating payment on a claim for services rendered are described. The process includes formatting data related to a medical service to be rendered to a patient in a mock claim, applying pricing rules that are unique to an agreement between payer entity and a provider of the service; and determining an estimated payment for the medical service to be paid by the payer to the provider after the medical service has been rendered to the patient.