Request for Application #2019-016

openIMIS Modularization, Nepali Functionality, and Community Development

JLN-Claims-Management and Automation of AI and ML fraud Detection

Two-sentence overview: 

Healthcare claims management is the single most expensive process done by the payers. The JLN Processes (Claims Management) and the development of Automated Claims Processing with fraud detection using ML and AI technologies are two tasks that Healthix Solutions will be looking to work on in the OpenIMIS project.

Claims management and payment processing currently involves lots of manual processes including:- data gathering, benefit plans mapping and matching, correctly configure deductions and accounting for the payments done.

Executive summary: 

The OpenIMIS initiative drives an interoperable agenda for both the provider and payer players globally. The current deployments in Nepal and Tanzania have priority developments focused on Claims Management, and Members management that would greatly impact efficiency for the different stakeholders.

As Healthix, we wish to replicate our success in Kenya to Nepal where we have developed and deployed similar integrated solutions for Payer and Provider stakeholders. We shall automate claim processing with fraud detection while improving on the JLN Processes of improving Claims Management.

Today, Artificial Intelligence (AI) techniques such as Machine Learning (ML) can be used to discover patterns from non-linear datasets (Figure 2).

The AI techniques are coded to ensure that the predictable and linear processes can be flagged out in the claims as early as during submission. Figure 3 shows the sample AI processes that we shall use to discover linear flags that need to be watched.

Based on the learned pattern, the algorithms can predict payments on a claim; or even identify potential fraudulent claims and flag them for investigation. Insurers now have the option of achieving far better claims management by utilizing the technology in the following ways:

  1. Use rule-based engine to pre-assess claims while automating the evaluation process.
  2. Use artificial intelligence to automate claims fraud detection through rich data analytics.
  3. Use machine learning to predict patterns of claim volume.
  4. Augment loss analysis.

Improved Claim Review

The Improved Claim Review requirement describes two distinct mechanisms aiming at Claim processing automation. To enhance openIMIS functionality, our specific assignment will be to improve the functionality of the new platform by providing Python-based Configurable Claim Review Engine; and AI-based Claim Automated Adjudication and fraud detection.

 

Consortium Team: 

Consortium Team

Healthix Solutions registered in Kenya is the lead in this development and deployment of digital health insurance solutions. Healthix is a technology company specializing in Healthcare (Providers) and Insurance (Payers) industry; connecting Insurance/Payers and Providers with a focus to improve patient care. We are enabling a vibrant Healthcare Ecosystem through a Shared Exchange platform (Enterprise Bus) we have developed (seamless integrated exchange services between all Healthcare players).

We provide value in Claims submission, Referral management, Preauthorization requests & responses, member eligibility verification and tracking, Claims adjudication and payment management amongst other services. The shared enterprise gateway makes it possible for the different players to exchange data real-time.

Our team is versatile and well blended to provide expertise in medical health, insurance segment, analytics and visualizations. Our experience spans more than 20 years in senior Level management and technology deployment with specialty is in the development and operationalization of digital health platforms. We have project management, Product Architects, Account Managers, Terminology specialists, Software Developers and Payer expertise.

Workstream: 
Nepal Feature Requests
WHO Classification: 
Shared Health Record and health information repositories
Final Technical Application: 
Application Tags: 
interoperability
universal health coveage
master facility list
product registry
terminology service
Application Status: 
Pending Review & Investment

Comments

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In your final proposal you might want to specify a bit more precisely which tools out side of the openIMIS package will be needed and how they should be integrated that the entire solution can be distributed as open source. Also clearly state the contribution to the code base of openIMIS.

In your final proposal you might want to specify a bit more precisely which tools out side of the openIMIS package will be needed and how they should be integrated that the entire solution can be distributed as open source. Also clearly state the contribution to the code base of openIMIS.