logo BDSP

Base documentaire

  1. Design and implementation of an expert system for controlling health care costs.

    Article - En anglais

    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

    Logo du centre Notice produite par :
    Inist-CNRS - Institut de l'Information Scientifique et Technique

    Cote : 94-0447335

    Code Inist : 002B28E. Création : 199406.