Patent Application
20140278559
The present invention, in some embodiments thereof, relates to adjudication platforms and, more specifically, but not exclusively, to verification of multi-aspect adjudication platforms compliance with requirements and ongoing management of multi-aspect adjudication platforms.
Adjudication platforms are tools implementing insurance policies. Automated and semi-automated adjudication platforms are used in different fields of everyday life, such as banking, actuary and insurance. Banking adjudication platforms may be used to determine customers' commission rates according to variables pertaining to the individual customer, for example overall asset holdings and credit history. In the field of property insurance, adjudication platforms are used to apprise the equitable transfer of the risk of a loss, according to variables such as the situation which led to the damage, monetary value of stolen goods in case of a theft, and/or the like. Adjudication platforms are typically complex, such that decision making in such platforms is performed according to many adjudication platform aspects.
Customization of adjudication platforms according to the individual needs of different clients is sometimes required. In the field of health insurance, for example, healthcare providers implement an adjudication program which is typically a standard insurance product. The insurance product dictates treatments and procedures to be supplied at a reduced cost to a client by a Preferred Provider Organization (PPO). A client may request certain exceptions as a condition for renewal of a health adjudication platform such that, when implemented, the client's health adjudication platform no longer conforms to strictly PPO.
Adjudication platforms are often implemented as software. Some of the common uses of computerized adjudication platforms are claim processing by healthcare providers and/or paying entities, and claim pre-processing for predicting service approval. Patient services provided by healthcare providers, such as hospitals, clinics, physicians or practitioner nurses are reimbursed by paying entities such as a healthcare institution or a fellow healthcare provider. The reimbursement process often begins by sending claims to paying entities. Claims are provided electronically or in a paper format. Electronic claims are processed in adjudication platforms of paying entities. The claims are interpreted and their status is determined as pay in full, partial payment or denied. The level of automation in such a process varies from fully automated to manual, with many intermediate levels.
According to an aspect of some embodiments of the present invention there is provided a computerized method of verifying compliance of a plurality of benefit rules with a plurality of requirements, the method comprising: acquiring a plurality of benefit rules of an adjudication platform; applying a plurality of requirements representing at least one of a law and a policy to the plurality of benefit rules; identifying at least one of the plurality of benefit rules disagreeing with at least one of the plurality of requirements, responsive to a discrepancy between applied plurality of requirements and the plurality of benefit rules; outputting at least one of identified the plurality of benefit rules and the plurality of requirements.
Optionally, the method applies a plurality of requirements to the plurality of benefit rules is performed by: identifying a plurality of assignments for at least one of the plurality of requirements; associating at least one subset of the plurality of assignments with at least one of the plurality of benefit rules according to agreement of the at least one subset with the at least one of the plurality of benefit rules; choosing a second benefit rule from the plurality of benefit rules according to at least one relationship of the second benefit rule with the at least one of the plurality of benefit rules; adding at least one assignment for the second benefit rule to the at least one subset; comparing an eligibility result of the second benefit rule with an expected result of the at least one of the plurality of requirements. Optionally, the method further comprises repeating the choosing and adding until at least one of getting to an eligibility result and identifying a logical contradiction between the plurality of assignments. Optionally, the plurality of assignments includes all possible assignments. Optionally, the plurality of assignments comprises at least one of a plurality of numerical eligibility characteristics, a plurality of textual tags, and a plurality of formulas. Optionally, discrepancy between applied plurality of requirements and the plurality of benefit rules is at least one of: a contradiction between the plurality of assignments, a contradiction between a plurality of variables of an assignment from the plurality of assignments, an empty assignment set, a difference in an eligibility result of at least one of the plurality of benefit rules and an eligibility result of at least one of the plurality of requirements and a benefit rule which is never assessed. Optionally, at least one relationship is at least one of a sequence and a hierarchy. Optionally, identifying a plurality of assignments for at least one of the plurality of requirements is performed by at least one of satisfiability solver, theorem prover and abstract interpretation. Optionally, the method further comprises: automatically recognizing a revision of at least one of the plurality of benefit rules; automatically repeating the applying, the identifying and the outputting responsive to the revision. Optionally, the method further comprises: automatically recognizing a revision of at least one of the plurality of requirements; repeating the applying, the identifying and the outputting upon a revision of the plurality of benefit rules. Optionally, at least one of a law and a policy comprises a member of a group consisting of: a state regulation, a state law, a federal regulation, a federal law, and guidelines of an insurance policy. Optionally, the plurality of requirements is generated by converting at least one of a law and a policy. Optionally, the method further comprises: translating each of the plurality of benefit rules to at least one logical language statement; representing the at least one logical language statement as a mathematical graph. Optionally, the mathematical graph comprises a plurality of nodes and a plurality of edges; and the representing the at least one logical language statement as a mathematical graph comprises associating a plurality of propagation functions with the plurality of edges, wherein each propagation function is one or more conditional instructions determining data flow along associated edge according to validity of the conditional instructions. Optionally, the method further comprises: associating at least one subset of a plurality of assignments with at least one of the plurality of propagation functions. Optionally, the plurality of benefit rules complies with the plurality of requirements the outputting comprises a compliance indication. Optionally, the plurality of benefit rules represents an adjudication platform; the plurality of requirements represents the adjudication platform; and a representation of the plurality of benefit rules differs from a representation of the plurality of requirements. Optionally, the method further comprises: acquiring a relationships database indicating at least one of: a plurality of relationships between a plurality of benefit rule eligibility characteristics, each defining a characteristic for complying with a benefit rule; a plurality of relationships between a plurality of requirement eligibility characteristics, each defining a characteristic for complying with a requirement; a plurality of relationships between at least one of the plurality of benefit rule eligibility characteristics and at least one of the plurality of requirement eligibility characteristics; wherein the identifying at least one of the plurality of benefit rules disagreeing with at least one of the plurality of requirements, utilizes at least one of the plurality of relationships of the relationships database. Optionally, the plurality of relationships comprises: a type-of relationship, a containing relationship, a part-of relationship and a is-a relationship.
According to some embodiments of the invention, there is provided a computerized method of verifying self consistency of an adjudication platform, the method comprising: assigning at least one of a plurality of formulas and a plurality of eligibility characteristics to a plurality of benefit rules representing an adjudication platform; identifying a fault in at least one of the plurality of benefit rules, the fault comprising: a contradiction between the plurality of benefit rules, repetition of a benefit rule, a benefit rule which is always true, a benefit rule which is always false and a benefit rule which is never assessed.
According to some embodiments of the invention, there is provided a computer program product for verifying compliance of a plurality of benefit rules with a plurality of requirements, comprising: a computer readable storage medium; first program instructions to apply a plurality of requirements to plurality of benefit rules; second program instructions to identify a discrepancy between applied the plurality of requirements and the plurality of benefit rules; and third program instructions to output the discrepancy; wherein the first, second and third program instructions are stored on the computer readable storage medium.
According to an aspect of some embodiments of the present invention there is provided a system for verifying compliance of a plurality of benefit rules with a plurality of requirements, the system comprising: a processor; a calculation module which, using the processor, applies a plurality of requirements to a plurality of benefit rules, wherein the calculation module identifies at least one of the plurality of benefit rules disagreeing with at least one of the plurality of requirements; and an interface module which acquires the plurality of benefit rules, acquires the plurality of requirements, and outputs identified disagreeing at least one of the plurality of benefit rules.
Optionally, the system further comprises a requirement generating module, the requirement generating module generating the plurality of requirements by converting at least one of a law and a policy into the plurality of requirements
Unless otherwise defined, all technical and/or scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the invention pertains. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of embodiments of the invention, exemplary methods and/or materials are described below. In case of conflict, the patent specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and are not intended to be necessarily limiting.
Some embodiments of the invention are herein described, by way of example only, with reference to the accompanying drawings. With specific reference now to the drawings in detail, it is stressed that the particulars shown are by way of example and for purposes of illustrative discussion of embodiments of the invention. In this regard, the description taken with the drawings makes apparent to those skilled in the art how embodiments of the invention may be practiced.
In the drawings:
The present invention, in some embodiments thereof, relates to adjudication platforms and, more specifically, but not exclusively, to verification of adjudication platforms' benefit rules compliance with requirements and ongoing management of adjudication platforms.
As used herein, the term “requirement” means a requirement, an instrument containing a set of rules. The rules may have the force of the law and/or may represent an entity's matter of course. A requirement may be a federal law, a state law, a federal requirement, a state requirement, a policy, and/or guidelines. The requirement may be provided as a written document, a set of logical expressions, a code in a machine readable format and other forms and formats capturing a requirement.
Policies, such as real estate insurance policies, health adjudication platforms etc., have to comply with requirements, such as federal mandates, state laws, state requirements etc. For example, the state of New Jersey mandates that yearly blood glucose tests should be covered for all adults who are over 20 years old, and that glaucoma eye tests are covered every 5 years for adults over age 35.
Requirements are in an ever changing state as new requirements are issued, and existing requirements are updated. Health policies, and the adjudication platforms representing them, have to keep up with these changes. Federal mandates require that the official orders are implemented within the adjudication platform product. Implementing such official orders as part of an adjudication platform product is difficult as the ontology, sequence, relationship types between elements, and/or logic may differ between the official order and the policy.
Adjudication platforms customization may become a source of implementation faults. It is important for owners, such as insurance companies, healthcare providers and organizations providing claim processing services, to track and govern such exceptions, and to identify exceptions which are not implemented correctly within the policy. It is also important to identify variants of the adjudication platform product when migrating to a new health adjudication platform management system.
Automated computerized adjudication platforms implementing adjudication platforms, as any other software, go through ongoing code maintenance. Changes to code may modify its self-consistency, its agreement with the policy it represents and/or its compliance with requirements.
Assessing compliance of an adjudication platform with a requirement can be performed by: 1) Conducting a manual inspection of the implemented benefit rules within a policy 2) Testing exemplary claims in a “black box” approach. Both possibilities are error-prone and labor-intensive processes.
For the purpose of illustration, embodiments of the present invention will be demonstrated herein using a specific example of a health insurance program.
Embodiments of the present invention enable automated verification of health policy implementations compliance with a health policy. An adjudication platform is implemented as a computerized model. The code of such a computerized model contains benefit rules of the adjudication platform and the sequence, hierarchy and/or flow between them. A graph, such as a Control Flow Graph (CFG) is generated according to this code. Each requirement is applied to the graph to inspect its compliance. The application is performed by choosing a subset of relevant benefit rule eligibility characteristics and assigning combinations of numerical eligibility characteristics and/or textual tags in them. The results of these assignments are inspected for compliance with the requirements and/or for self-consistency.
Before explaining at least one embodiment of the invention in detail, it is to be understood that the invention is not necessarily limited in its application to the details of construction and the arrangement of the components and/or methods set forth in the following description and/or illustrated in the drawings and/or the Examples. The invention is capable of other embodiments or of being practiced or carried out in various ways.
As will be appreciated by one skilled in the art, aspects of the present invention may be embodied as a system, method or computer program product. Accordingly, aspects of the present invention may take the form of an entirely hardware embodiment, an entirely software embodiment (including firmware, resident software, micro-code, etc.) or an embodiment combining software and hardware aspects that may all generally be referred to herein as a “circuit,” “module” or “system.” Furthermore, aspects of the present invention may take the form of a computer program product embodied in one or more computer readable medium(s) having computer readable program code embodied thereon.
Any combination of one or more computer readable medium(s) may be utilized. The computer readable medium may be a computer readable signal medium or a computer readable storage medium. A computer readable storage medium may be, for example, but not limited to, an electronic, magnetic, optical, electro-magnetic, infrared, or semiconductor system, apparatus, or device, or any suitable combination of the foregoing. More specific examples (a non-exhaustive list) of the computer readable storage medium would include the following: an electrical connection having one or more wires, a portable computer diskette, a hard disk, a random access memory (RAM), a read-only memory (ROM), an erasable programmable read-only memory (EPROM or Flash memory), an optical fiber, a portable compact disc read-only memory (CD-ROM), an optical storage device, a magnetic storage device, or any suitable combination of the foregoing. In the context of this document, a computer readable storage medium may be any tangible medium that can contain, or store a program for use by or in connection with an instruction execution system, apparatus, or device.
A computer readable signal medium may include a propagated data signal with computer readable program code embodied therein, for example, in baseband or as part of a carrier wave. Such a propagated signal may take any of a variety of forms, including, but not limited to, electro-magnetic, optical, or any suitable combination thereof. A computer readable signal medium may be any computer readable medium that is not a computer readable storage medium and that can communicate, propagate, or transport a program for use by or in connection with an instruction execution system, apparatus, or device.
Program code embodied on a computer readable medium may be transmitted using any appropriate medium, including but not limited to wireless, wire line, optical fiber cable, RF, etc., or any suitable combination of the foregoing.
Computer program code for carrying out operations for aspects of the present invention may be written in any combination of one or more programming languages, including an object oriented programming language such as Java, Smalltalk, C++ or the like and conventional procedural programming languages, such as the “C” programming language or similar programming languages. The program code may execute entirely on the user's computer, partly on the user's computer, as a stand-alone software package, partly on the user's computer and partly on a remote computer or entirely on the remote computer or server. In the latter scenario, the remote computer may be connected to the user's computer through any type of network, including a local area network (LAN) or a wide area network (WAN), or the connection may be made to an external computer (for example, through the Internet using an Internet Service Provider).
Aspects of the present invention are described below with reference to flowchart illustrations and/or block diagrams of methods, apparatus (systems) and computer program products according to embodiments of the invention. It will be understood that each block of the flowchart illustrations and/or block diagrams, and combinations of blocks in the flowchart illustrations and/or block diagrams, can be implemented by computer program instructions. These computer program instructions may be provided to a processor of a general purpose computer, special purpose computer, or other programmable data processing apparatus to produce a machine, such that the instructions, which execute via the processor of the computer or other programmable data processing apparatus, create means for implementing the functions/acts specified in the flowchart and/or block diagram block or blocks.
These computer program instructions may also be stored in a computer readable medium that can direct a computer, other programmable data processing apparatus, or other devices to function in a particular manner, such that the instructions stored in the computer readable medium produce an article of manufacture including instructions which implement the function/act specified in the flowchart and/or block diagram block or blocks.
The computer program instructions may also be loaded onto a computer, other programmable data processing apparatus, or other devices to cause a series of operational steps to be performed on the computer, other programmable apparatus or other devices to produce a computer implemented process such that the instructions which execute on the computer or other programmable apparatus provide processes for implementing the functions/acts specified in the flowchart and/or block diagram block or blocks.
Reference is made to
According to some embodiments of the present invention, the compliance of an adjudication platform's implementation with those same adjudication platform guidelines is examined. The adjudication platform has two roles here: one as a requirement and another as benefit rules of an adjudication platform, allowing the adjudication platform to be applied to it-self. The adjudication platform may be provided as two different representations: for example as a source code implementation and as a graph. The two representations may be generated by different generation processes: employing diverse generation methodologies and/or dissimilar creators. Disparity in generation processes may lead to disparity in faults of adjudication platform representing. Each representation may involve one or more steps of translation, conversion and/or transformation. Each of these steps is prone to faults and errors. Different presentation generation processes may result in different faults and/or errors in the result presentation. Unalike presentations are not likely to harbor the same faults and/or errors. Comparing the presentations may reveal these faults and/or errors should they occur, and enable to verify the correctness of the adjudication platform presentation.
Reference is also made to
For brevity, the following is formally defined:
Let m 210 and n 230 be nodes in a CFG graph. Each node in the graph is associated with a propositional function fv. Here node m 210 is associated with the propositional function fv(m,n) 212.
Let Vv be the set of all eligibility characteristics of a propositional function fv(m,n) 212.
An edge from node m 210 to node n 230 is denoted (m,n) 222. Each edge (m,n) 222 is associated with a propagation function 220 denoted fe(m,n). The propagation function 220, fe (m,n), represents the change of the relevant data as control passes from the start of m 210 to the start of n 230.
Let Ve be the set of all eligibility characteristics of a propagation function 220, related to an edge, fe(m,n). Ve is the same as or a subset of Vv (the domain of the input)—the set of all eligibility characteristics of a propositional function. fv(m,n) is the result.
Let P(A) be the set of all assignment as 211. P(A) is the entire set of combinations of Vv—the set of all eligibility characteristics of a propositional function fv(m,n) 212. A claim, such as a medical claim for a health adjudication platform, is represented by a particular assignment to Vv.
Let C be a set of assignments (i.e. claims) 211 that are associated with node m 210. When applying the propagation function 220, fe(m,n), to C 211—the result is an assignment set C′ 231: fe(m,n) (C)=C′. C′ 231 is equal to or a subset of C 211.
Optionally, each test node 210 has two edges: etrue 222 and efalse 223 leading to true and false successors: 230 and 240. Each edge 222, 223 is associated with a true or false propagation function ƒtrue 220 and ƒfalse 221.
ftrue(1)={s|sε1s/=at}
ƒfalse={s/sε1|s/=at}
Reference is also made to
Optionally, the calculation module 302 may explore alternative benefit rules which correct the disagreement with the requirements. The output may further indicate such alternative benefit rules. Optionally, the system 300 also comprises a requirement generating module. The requirement generating module generates one or more requirement(s) by converting a law and/or an adjudication platform into multiple requirements. The requirement generation may comprise a conversion, adaptation, translation, transformation and/or formatting of a law and/or an adjudication platform into a desired representation suitable for the calculation module 302 such as a set of logical statements, logical expressions, a mathematical graph, a CFG, a machine readable code and/or a flowchart.
Reference is also made to
IF age>=35 years and #_of_claims(procedure=Glaucoma_test, period=5 years)=0 THEN copay=$0
The glaucoma test provision is transformed into the following representation:
Age_over—35∩number_of_claims_glaucoma_test_in—5_years_is—0→copay—0
An adjudication platform implements benefit rules, among them the following health benefit rule:
IF age>=35 years and #_of_claims(procedure=Glaucoma_test, period=5 years)=0 THEN copay=$0
This benefit rule is introduced as a set of Boolean eligibility characteristics in a logical expression:
IF age<35 years or number_of_claims(procedure=Glaucoma_test, period=5 years)>0 THEN copay=$100
When coded, the condition (age>=35) is transformed into the Boolean argument ‘age_over—35’ which may be assigned an eligibility characteristic of 1 if true or 0 if false. Similarly, the condition number_of_claims(procedure=Glaucoma_test, period=5 years)=0 is transformed into the Boolean argument: number_of_claims_glaucoma_test_in—5_years_is—0.
The Boolean expressions are then represented as propositional functions 212 in a graph 400:
! Age_more_then—35 Or ! number_of_claims_glaucoma_test_in—5_years_is—0
This Boolean expression 401A is associated with a test node 401. The graph elements are as described in
S 411 denotes the assignments which meet the glaucoma test provision, and is selected as:
S={{Age_over—35=1, number_of_claims_glaucoma_test_in—5_years_is—0=1}}
S 411 is a subset of L. Here S 411 is the input for the first test node 401. The node 401 has two propagation functions 404, 405 which are related to the propositional function 401A: A true eligibility characteristic for the propositional function 401A is represented by the propagation function of the right-hand edge 405, while a false eligibility characteristic for the propositional function 401A is represented by the propagation function of the left-hand edge 404. Applying the left-hand propositional function to S 411 results in an empty set. This agrees with the requirement as none of the assignments of S should result in a co-pay of $100 according to node 402. Applying the right-hand propositional function to S 411, results in the assignment set 413. The assignment set 413 and S 411 are identical. This agrees with the requirement all of the assignments of S should result in a co-pay of $0 according to node 403. The verification concludes that the adjudication platform implementation 400 conforms to the Glaucoma test requirement.
Reference is also made to
In the graph, each elliptical node 504, 505, 401-403 represents a test node and is associated with a propositional function 212 or a target eligibility characteristic 402A, 403A, 505A. The horizontal line 501 splits the graph 500 into two parts: upper 502 and lower 503. The lower part 503 is as described in
Reference is also made to
The methods as described above are used in the fabrication of integrated circuit chips.
The flowchart and block diagrams in the Figures illustrate the architecture, functionality, and operation of possible implementations of systems, methods and computer program products according to various embodiments of the present invention. In this regard, each block in the flowchart or block diagrams may represent a module, segment, or portion of code, which comprises one or more executable instructions for implementing the specified logical function(s). It should also be noted that, in some alternative implementations, the functions noted in the block may occur out of the order noted in the figures. For example, two blocks shown in succession may, in fact, be executed substantially concurrently, or the blocks may sometimes be executed in the reverse order, depending upon the functionality involved. It will also be noted that each block of the block diagrams and/or flowchart illustration, and combinations of blocks in the block diagrams and/or flowchart illustration, can be implemented by special purpose hardware-based systems that perform the specified functions or acts, or combinations of special purpose hardware and computer instructions.
The descriptions of the various embodiments of the present invention have been presented for purposes of illustration, but are not intended to be exhaustive or limited to the embodiments disclosed. Many modifications and variations will be apparent to those of ordinary skill in the art without departing from the scope and spirit of the described embodiments. The terminology used herein was chosen to best explain the principles of the embodiments, the practical application or technical improvement over technologies found in the marketplace, or to enable others of ordinary skill in the art to understand the embodiments disclosed herein.
It is expected that during the life of a patent maturing from this application many relevant systems and methods will be developed and the scope of the terms adjudication frameworks, simplification instructions and appraisal table is intended to include all such new technologies a priori.
As used herein the term “about” refers to ±10%.
The terms “comprises”, “comprising”, “includes”, “including”, “having” and their conjugates mean “including but not limited to”. This term encompasses the terms “consisting of” and “consisting essentially of”.
The phrase “consisting essentially of” means that the composition or method may include additional ingredients and/or steps, but only if the additional ingredients and/or steps do not materially alter the basic and novel characteristics of the claimed composition or method.
As used herein, the singular form “a”, “an” and “the” include plural references unless the context clearly dictates otherwise. For example, the term “a compound” or “at least one compound” may include a plurality of compounds, including mixtures thereof.
The word “exemplary” is used herein to mean “serving as an example, instance or illustration”. Any embodiment described as “exemplary” is not necessarily to be construed as preferred or advantageous over other embodiments and/or to exclude the incorporation of features from other embodiments.
The word “optionally” is used herein to mean “is provided in some embodiments and not provided in other embodiments”. Any particular embodiment of the invention may include a plurality of “optional” features unless such features conflict.
Throughout this application, various embodiments of this invention may be presented in a range format. It should be understood that the description in range format is merely for convenience and brevity and should not be construed as an inflexible limitation on the scope of the invention. Accordingly, the description of a range should be considered to have specifically disclosed all the possible subranges as well as individual numerical values within that range. For example, description of a range such as from 1 to 6 should be considered to have specifically disclosed subranges such as from 1 to 3, from 1 to 4, from 1 to 5, from 2 to 4, from 2 to 6, from 3 to 6 etc., as well as individual numbers within that range, for example, 1, 2, 3, 4, 5, and 6. This applies regardless of the breadth of the range.
Whenever a numerical range is indicated herein, it is meant to include any cited numeral (fractional or integral) within the indicated range. The phrases “ranging/ranges between” a first indicate number and a second indicate number and “ranging/ranges from” a first indicate number “to” a second indicate number are used herein interchangeably and are meant to include the first and second indicated numbers and all the fractional and integral numerals therebetween.
It is appreciated that certain features of the invention, which are, for clarity, described in the context of separate embodiments, may also be provided in combination in a single embodiment. Conversely, various features of the invention, which are, for brevity, described in the context of a single embodiment, may also be provided separately or in any suitable sub-combination or as suitable in any other described embodiment of the invention. Certain features described in the context of various embodiments are not to be considered essential features of those embodiments, unless the embodiment is inoperative without those elements.
Although the invention has been described in conjunction with specific embodiments thereof, it is evident that many alternatives, modifications and variations will be apparent to those skilled in the art. Accordingly, it is intended to embrace all such alternatives, modifications and variations that fall within the spirit and broad scope of the appended claims.
All publications, patents and patent applications mentioned in this specification are herein incorporated in their entirety by reference into the specification, to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated herein by reference. In addition, citation or identification of any reference in this application shall not be construed as an admission that such reference is available as prior art to the present invention. To the extent that section headings are used, they should not be construed as necessarily limiting.
