Improved Claims Review

Current openIMIS claims review process

The current claims review process in openIMIS follows a mixed approach including automated and manual procedures. Once a health facility submits a claim, a fixed list of automated checks is conducted on the claim, which results in either the claim to be fully or partially accepted, or rejected. These automated checks are based on the definition of the beneficiary, the product (insurance scheme definition), services, and items. 

Example

If a claim for providing a Normal Delivery service to a Female of 25 yrs of age (who is covered by a product that includes all services in the National Health Insurance of Nepal) is entered by Health Facility A, openIMIS will check against a few criteria automatically before presenting the claim for manual review for the scheme operator.

Assumptions of some definitions are presented in Table 1. In this case, the claim would be accepted as the beneficiary has an active policy, has an available credit covering the cost of the service claimed, is a Female, and this is the first time a delivery service is claimed for this beneficiary.  This claim would now appear on the screen of the claim review team of the scheme operator for manual review.

However, if the same claim (or similar, but including the delivery service) is entered again before 01 Jan 2020, the claim will be rejected as it will not meet the criteria defined under Service Definition - Once every calendar year.

These automated checking processes within openIMIS are fixed, and not configurable by the user. While it is possible to configure the time between claiming of the same service resulting in rejection, it is not possible to add new checks on other fields. A configurable rules engine that will enable the automatic assessment of claims in by testing against various knows scenarios (eg. what services cannot be claimed for a particular diagnosis) would heavily ease the workload for the claim review team of the scheme operator.

Configurable Claims Review Engine

Automated Claims Adjudication

Technical Requirements

The claims review engine should align with the modularization roadmap of openIMIS. It is envisioned that the improved claims review engine would be written as a standalone service that utilizes a HL7 FHIR data store as the data input for the claim engine, in particular the FHIR Financial Module resources.    This service would include the rules engine as well as user interfaces.  This service would then be integrated in the openIMIS software as well as be available for the management of insurance schemes that do not use openIMIS but wish for advanced claim management functionality (e.g. PhilHealth).  The claims review engine should be written so that future iterations can make use of advances in Machine Learning and Artificial Intelligence to improve the accuracy of identification of misfiled claims and to reduce the time involved by health workers in resolving claims.