DESIGN AND IMPLEMENTATION OF AN EXPERT-SYSTEM FOR CONTROLLING HEALTH-CARE COSTS
成果类型：
Article
署名作者：
MARTIN, JL; HARRISON, TP
刊物名称：
OPERATIONS RESEARCH
ISSN/ISSBN：
0030-364X
DOI：
10.1287/opre.41.5.819
发表日期：
1993
页码：
819-834
关键词：
摘要：
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 ''pert knowledge to evaluate the paid claims. We examine the use of a simple ''pert 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.