Many firms with self-funded medical insurance administered by outside parties fail to review the administrators' performance effectively.
Often the firms do not know the extent of overpayments because they lack the expert knowledge to evaluate the paid claims.
We examine the use of a simple expert system in conjunction with optimization methods for identifying claims payment errors.
The knowledge base is constructed using expertise from the areas of claims processing, auditing, medical diagnosis, and procedure coding practices.
Once potential errors are identified, a mathematical program is used to select claims for audit based on maximizing expected benefits subject to various firm-specific processing limitations.
Mots-clés Pascal : Système expert, Gestion, Coût, Santé, Economie santé, Réclamation, Paiement, Erreur, Assurance maladie, Etats Unis, Amérique du Nord, Amérique, Informatique biomédicale
Mots-clés Pascal anglais : Expert system, Management, Costs, Health, Health economy, Protest, Payment, Error, Health insurance, United States, North America, America, Biomedical data processing
Notice produite par :
Inist-CNRS - Institut de l'Information Scientifique et Technique
Cote : 94-0447335
Code Inist : 002B28E. Création : 199406.