A three-stage auditing framework to minimize medical necessity claim denials

Faisal Aqlan, Sang Won Yoon, Mohammad T. Khasawneh, Krishnaswami Srihari

Research output: Chapter in Book/Report/Conference proceedingConference contribution

Abstract

This research presents a three-stage auditing framework to minimize medical necessity insurance claim denials. The objective of this research is to detect potential insurance claim denials, due to medical necessity errors, before filing the claims to health insurers. The proposed auditing framework focuses on monitoring medical necessities and patient insurance coverages at different stages, such as patient registration, procedures and treatments, and billing and claim filing. A set of auditing rules and knowledge-base from historical medical necessity cases and claims are proposed to detect potential insurance claim denial cases. In addition, continuous auditing rule updates are proposed to maintain up-to-date patient records, insurance guidelines, medical codings, and clinical standards. As a result, potential insurance claim denial cases can be minimized, such that additional services to resolve the given claims can also be minimized. The proposed auditing framework has been tested using simulation experiments.

Original languageEnglish (US)
Title of host publication61st Annual IIE Conference and Expo Proceedings
PublisherInstitute of Industrial Engineers
StatePublished - 2011
Event61st Annual Conference and Expo of the Institute of Industrial Engineers - Reno, NV, United States
Duration: May 21 2011May 25 2011

Other

Other61st Annual Conference and Expo of the Institute of Industrial Engineers
CountryUnited States
CityReno, NV
Period5/21/115/25/11

All Science Journal Classification (ASJC) codes

  • Industrial and Manufacturing Engineering

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