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Requirement is a Database for Health Insurance Claims.
The User is a small insurance auditing firm (under contract with hospitals nationwide).
There are several areas needing automation.
Breaking down the organization, we have management, auditors, and claims processors.
The Claims processing begins when the Auditors forward a report to a Claims Processor,
who contacts the Insurance Company to let them know they underpaid (and the battle begins).
Right now the claims processors do everything by paper.
They get the report from the auditor (paper), track who they called, at what insurance company, what time,
for how long, what Patient they were calling in reference to, and the list goes on (all on paper).
All of this handwriting obviously takes up a huge amount of time, which is less time spent on the phone.
As a result, Claims Processors, whose time is supposed to be spent on the phone harrassing insurance companies, are
in fact, spending a huge amount of time writing on reports and filling out caller logs instead.
A. The Business process :-
The auditing process involves :-
Step 1) Large amounts of data is received from hospitals extracted from their systems (usually in *.txt),
Step 2) The data is analyzed using MS Excel,
Step 3) Claims that have been underpaid are flagged.
Step 4) Flagged data is printed in report format.
B. Things of Interest :-
B.1 Auditors
B.2 Claims
B.3 Claims Processors
B.4 Hospitals
B.5 Hospital Data
B.6 Insurance Companies
B.7 Patients
B.8 Staff
C. How are they related ?
C.1 A Claim can be associated with zero or one Claims Processor.
C.2 A Claims Processor can be associated with zero, one or many Claims.
Barry Williams
12th. May 2003
Principal Consultant
Database Answers