Health reinsurance rule engine: approach

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Rule Engine - Munich Re

Approach

Rule Engine

Efficiency is the rule

The Rule Engine is integrated into your claims handling workflow. Information on and clients is added to the system’s knowledge base, a comprehensive set of predefined basic rules that replicates the global expertise pooled in Munich Health. This enables the Rule Engine to check incoming claims regarding all relevant medical information including the patient’s age and gender, diagnosis, medical procedures, prescribed drugs etc. The tool then automatically evaluates the medical appropriateness and billing correctness of the submitted invoices or requests for preauthorization.

Should a mismatch emerge between diagnosis and procedure, diagnosis and drug or procedure and gender, the claim is rejected. The result: no further processing the incorrect claim, no payment, no cost incurred in claiming back an unjustified payment. Experience shows that fraudulent claims detected before they are paid seldom lead to legal disputes with clients or providers.

With the capacity to process as many as 50,000 claims in a single day, the Rule Engine can significantly enhance your accuracy and efficiency in claims handling. A large health insurer in the Middle East saw its auto-adjudication rate rise significantly – up to 50% of all its claims are currently processed without further manual intervention. And the tool can be tailored to meet your needs and market conditions and continuously fine-tuned by incorporating your experiences.

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This publication is available exclusively to Munich Re clients. Please contact your Client Manager.