A HYBRID SYSTEM IMPROVES CLAIMS AUDITING AT BLUE CROSS

The PlanTracker system helps Blue Cross of Western Pennsylvania (BCWP) to analyze errors in claims records transmitted from other Blue Cross organizations with the goal of improving their accuracy. The developm ent of PlanTracker was complicated by a complex and constantly changin g data transmission environment that impeded the formation of both des criptive models of human domain expertise and normative models based o n analysis of the claims data. We developed a hybrid system that compe nsated for these problems by utilizing statistical and heuristic knowl edge to assess claims data submissions over time. PlanTracker has redu ced the time required to audit claims information from seven days to a bout one hour, helping BCWP to increase the frequency and volume of it s records transmission and reduce errors in transmitted claims data. A s a result, BCWP has achieved a more timely and consistent billing cyc le for its corporate accounts. Since 1987, the dollar volume of claims rejected annually has decreased from 10 percent to 4.5 percent.