Understanding healthcare claims processing and risk adjustment with IDP
When a medical claim is submitted, the insurance provider (payer) must process the claim to determine their correct financial responsibility and that of the patient. The process is known as claims adjudication or claims processing. During this process, the claims go through various checks; one such check is coding-level validation. During this coding-level validation, we check for the accuracy of the medical diagnosis code. Most often, this step requires manual review by a medical professional. Can we automate this process by leveraging technology? The answer is yes.
We will use Amazon IDP for coding-level validation for accurate claims processing. For this exercise, we will use the CMS1500 claim form and also a doctor’s note. We will process these documents with Amazon Textract for the accurate extraction of elements along with the ICD-10-CM code. We will also process the doctor’s note to adhere...