Design and Implementation of an Expert System for Controlling Health Care Costs

Jack L. Martin and Terry P. Harrison
Additional contact information
Jack L. Martin: Pennsylvania State University, University Park, Pennsylvania
Terry P. Harrison: Pennsylvania State University, University Park, Pennsylvania

Operations Research, 1993, vol. 41, issue 5, 819-834

Abstract: 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. We use an efficient Lagrangian relaxation to solve instances of this pure binary programming problem with as many as 150,000 variables. We report on our experience in the use of this system on behalf of a Fortune 100 firm's claims data base.

Keywords: health care: health care insurance coverage; information systems: used in auditing health care claims; programming; integer; applications: Lagrangian relaxation (search for similar items in EconPapers)
Date: 1993
References: Add references at CitEc
Citations:

Downloads: (external link)
http://dx.doi.org/10.1287/opre.41.5.819 (application/pdf)

Related works:
This item may be available elsewhere in EconPapers: Search for items with the same title.

Export reference: BibTeX RIS (EndNote, ProCite, RefMan) HTML/Text

Persistent link: https://EconPapers.repec.org/RePEc:inm:oropre:v:41:y:1993:i:5:p:819-834

Access Statistics for this article

More articles in Operations Research from INFORMS Contact information at EDIRC.
Bibliographic data for series maintained by Chris Asher ().