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When You Hit a Wall, Go Around it Years ago we were hired by a Blue Cross/Blue Shield plan to look over a new Claims Processing system they were building. The focal point of their problems centered on adjudicating claims whereby they wanted to devise an automated way to analyze a claim and determine the amount of money to be paid out. They had spent a lot of time and money analyzing adjudication and were frustrated they couldn't come up with a standard algorithm for computing all claims. We studied the problem and found that 90% of their claims were easy to analyze and calculate adjudication. For example, simple doctor visits, a broken bone, normal childbirths, etc. were easy to analyze and compute. However, unusual medical claims such as complications at childbirth, and massive car accidents, involved many more variables and, consequently, were difficult to compute based on standard algorithms. After studying the problem carefully, we reached the conclusion that trying to accurately calculate 100% of all claims was an impossibility. It was simply not practical to try to achieve this lofty goal and, as such, was a waste of time pursuing it. Instead, it was our advice they simply automate the 90% claims they could easily perform and segregate the remaining 10% for handling by a human adjuster. To their surprise, this worked remarkably well and saved them considerable money.
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Article Source: http://www.articlesbase.com/programming-articles/when-you-hit-a-wall-go-around-it-421568.html  About the Author:Tim Bryce is a writer and management consultant with M. Bryce & Associates of Palm Harbor, Florida and has over 30 years of experience in the field. He is available for lecturing, training and consulting on an international basis. He can be reached at timb001@phmainstreet.com
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