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A Hybrid System Improves Claims Auditing at Blue Cross

Author

Listed:
  • Jerrold H. May

    (Artificial Intelligence in Management Laboratory, Joseph M. Katz Graduate School of Business, University of Pittsburgh, Pittsburgh, Pennsylvania 15260)

  • William E. Spangler

    (Artificial Intelligence in Management Laboratory, University of Pittsburgh)

  • Sean Chen

    (Artificial Intelligence in Management Laboratory, University of Pittsburgh)

  • Sharon L. Donohue

    (Knowledge Engineering Group, Blue Cross of Western Pennsylvania, Fifth Avenue Place, Suite 778, Pittsburgh, Pennsylvania 15222)

Abstract

The PlanTracker system helps Blue Cross of Western Pennsylvania (BCWP) to analyze errors in claims records transmitted from other Blue Cross organizations with the goal of improving their accuracy. The development of PlanTracker was complicated by a complex and constantly changing data transmission environment that impeded the formation of both descriptive models of human domain expertise and normative models based on analysis of the claims data. We developed a hybrid system that compensated for these problems by utilizing statistical and heuristic knowledge to assess claims data submissions over time. PlanTracker has reduced the time required to audit claims information from seven days to about one hour, helping BCWP to increase the frequency and volume of its records transmission and reduce errors in transmitted claims data. As a result, BCWP has achieved a more timely and consistent billing cycle for its corporate accounts. Since 1987, the dollar volume of claims rejected annually has decreased from 10 percent to 4.5 percent.

Suggested Citation

  • Jerrold H. May & William E. Spangler & Sean Chen & Sharon L. Donohue, 1993. "A Hybrid System Improves Claims Auditing at Blue Cross," Interfaces, INFORMS, vol. 23(6), pages 67-80, December.
    • Handle: RePEc:inm:orinte:v:23:y:1993:i:6:p:67-80
    DOI: 10.1287/inte.23.6.67
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    Cited by:

    1. Amelia A. Baldwin & Carol E. Brown & Brad S. Trinkle, 2006. "Opportunities for artificial intelligence development in the accounting domain: the case for auditing," Intelligent Systems in Accounting, Finance and Management, John Wiley & Sons, Ltd., vol. 14(3), pages 77-86, July.

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