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Insurance Claims Auditing System
     
Client Leading provider of computerized transaction processing, data communications and information services

Critical Issue The client processes their customer’s insurance claim forms. The Claims Management Solutions division required a system that would enable their customers to automatically audit these forms. Competitors already offered a similar solution; therefore the client not only needed to provide a like-solution, but also sought to surpass the competition in functionality, flexibility and maintainability of the system.

Reasons The system’s "time-to-market" was of primary importance. The competition was ahead of the curve by having their system already in place.

Vision Due to the client’s respected position in the market, more automobile repair estimates were being received daily than could be manually reviewed. Estimates that were incorrectly prepared or were over-billed could sneak through the system resulting in costly overpayments. The client envisioned a solution that would provide them with an accurate means of identifying which claim estimates were most likely to result in overpayments. This would therefore enable employees to focus their efforts towards addressing these estimates.

Solution Annams was chosen to facilitate and engineer the entire project.  Client’s task list included:
  • Analyzing, designing, developing, implementing and documenting the entire system. This included the database and application architecture.
  • Creating an interface for the insurance estimates stored in the mainframe to be downloaded into an AIX (Unix) based Oracle database, making any needed adjustments to the data (cleansing, deriving values, etc.).
  • Processing the estimates against the user configurable rules, displaying both the estimates and results of the audit through a Windows based application (Visual Basic) running on Personal Computers.
Claims from various automobile repair facilities are scanned against a user configurable set of rules (at multiple organizational levels with inheritance and security) and assigned a priority for review based on how they conform to those rules.  Offending claims can be viewed and approved for payment or returned (via e-mail). The system is flexible enough to be marketed to any of the client’s customers, regardless of their organizational structure. Many of their customers in this line of business are now utilizing the system, including Europe and the UK.

     
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