A three-stage auditing framework to minimize medical necessity claim denials

This research presents a three-stage auditing framework to minimize medical necessity insurance claim denials. The objective of this research is to detect potential insurance claim denials, due to medical necessity errors, before filing the claims to health insurers. The proposed auditing framework focuses on monitoring medical necessities and patient insurance coverages at different stages, such as patient registration, procedures and treatments, and billing and claim filing. A set of auditing rules and knowledge-base from historical medical necessity cases and claims are proposed to detect potential insurance claim denial cases. In addition, continuous auditing rule updates are proposed to maintain up-to-date patient records, insurance guidelines, medical codings, and clinical standards. As a result, potential insurance claim denial cases can be minimized, such that additional services to resolve the given claims can also be minimized. The proposed auditing framework has been tested using simulation experiments.