Making sense of healthcare benefits

Abstract

A key piece of information in healthcare is a patient's benefit plan. It details which treatments and procedures are covered by the health insurer (or payer), and at which conditions. While the most accurate and complete implementation of the plan resides in the payers claims adjudication systems, the inherent complexity of these systems forces payers to maintain multiple repositories of benefit information for other service and regulatory needs. In this paper we present a technology that deals with this complexity. We show how a large US health payer benefited from using the visualization, search, summarization and other capabilities of the technology. We argue that this technology can be used to improve productivity and reduce error rate in the benefits administration workflow, leading to lower administrative overhead and cost for health payers, which benefits both payers and patients.