Automating the insurance industry

I have worked on automating claims processing. It's not perfect. I didn't create the program, but I have a BS in Information Security and have been in Medicaid, Medicare, private insurance, etc, so I was the go between on the project. Basically, you create a program that adjudicates a claim without a human ever touching it. This includes claims that are extremely simple and are already going to be paid (for instance, an emergency ambulance ride). An actual examiner is needed for something more complicated that needs something like prior approval (an ambulance ride from a skilled nursing facility to a hospital that is not an emergency--although my company I worked for previously was catching up on how to automate this).

So now I'm on the opposite of that, I work in data mining. I'm looking for incorrectly paid claims using a SQL database of information from clients. The problem is that vendors use the auto adjudication programs (sometimes called mass adjudication) on claims that they shouldn't, resulting in incorrectly paid claims. My company comes in and recoups on them (one of my reports is terminated individuals because the system my client uses doesn't update correctly, so they end up paying claims to dead people without knowing it because auto adjudication isn't denying them--the technology just isn't smart enough yet).

It's a fairly messy process and I have worked in insurance for more than a decade. Every year the systems do get a little better, and I see a few more people let go because of it (for instance, there used to be second pass examiners for some claims; looking at a claim that is already processed and then processing it again with certain denials--those people were replaced by a program because it's very easy to figure out "this claim has X code and cannot be paid with Y code so Z code should be denied resulting in payment of only the X code--this is something I helped create by tracking the lifetime of claims across a system and seeing how long it took to process them and what could be done to reduce both the cost and the time it took to process them). Now my job is highly specialized, and I make more, so the article is correct. Simple jobs are disappearing, more skilled workers are needed.

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