idea_picMedinClaim introduces additional innovations to significantly improve insurer profits:

  • Capturing the know-how of experts and translating it into processing algorithms
  • Fully automating all stages of the process
  • Maintaining a centralized repository of insured data
  1. MedinClaim incorporates user-defined expert knowledge in medicine, insurance, regulation, and finance into a rule engine. Thousands of algorithms check the medical, administrative, and contractual aspects of each claim against a comprehensive collection of rules. All the expert know-how needed to process medical claims resides in the algorithms used to check each claim against insurance plans, patient records, policies, agreements, pre-authorizations, and more. The MedinClaim knowledge based can be easily maintained and updated by the user, without the need for programming expertise.
  2. Fully automated, parallel processing moves the claims efficiently through all the relevant modules, eliminating costly, time-consuming, and error-prone manual handling.
  3. Complete user control over the automated process enables payers to determine which algorithms to use for processing various types of claims. A flexible authorization mechanism allows the payer to specify the leeway different adjustors have in overriding the various rules.
  4. A centralized database stores data on the insured, claims, providers, codes, rules, and every other item needed for claim adjudication. As part of the database, MedinClaim maintains a repository of EMRs into which it captures data from CCDs and where it accumulates historical information about the insured, making it possible to verify that the CPT code matches the procedure actually performed, that the procedure matches the diagnosis, and to cross-check claim data across different claims, plans, and types of insurance, in order to detect fraud and eliminate overpayment.