Data Mining to Predict and Prevent Errors in Health Insurance Claims Processing

摘要

Health insurance costs across the world have increased alarmingly in recent years. A major cause of this increase are payment errors made by the insurance companies while processing claims. These errors often result in extra administrative effort to re-process (or rework) the claim which accounts for up to 30% of the administrative staff in a typical health insurer. We describe a system that helps reduce these errors using machine learning techniques by predicting claims that will need to be reworked, generating explanations to help the auditors correct these claims, and experiment with feature selection, concept drift, and active learning to collect feedback from the auditors to improve over time. We describe our framework, problem formulation, evaluation metrics, and experimental results on claims data from a large US health insurer. We show that our system results in an order of magnitude better precision (hit rate) over existing approaches which is accurate enough to potentially result in over $15-25 million in savings for a typical insurer. We also describe interesting research problems in this domain as well as design choices made to make the system easily deployable across health insurance companies.