Context-Aware Rule Engines for Pricing and Claims Processing in Healthcare Platforms

Abstract

The problem is that legacy rule engines in healthcare systems are rarely able to be flexible in real time, enable scale and make decision-making transparent. In this paper, the development of a context-aware rule engine to process pricing and claims is described on the basis of RESTful microservices and Spring MVC frameworks combined with caching technologies such as Couchbase. The engine has the capability of supporting upstream rule validation, contextual considerations at the session level and on-the-fly adjudication paths. The results reflect that the processing time, manual overrides and the costs of the operations have been reduced significantly. The architecture facilitates the payer-provider collaboration and compliance with improved auditability and transparency of decisions. The findings further highlight the fact that context-aware systems have the potential of transforming day-to-day business in the healthcare industry through the provision of intelligent and responsive moderately low-cost solutions to root out intractable claim and pricing logics.