I noticed it the way you notice most real problems: something small that should not have been there. Claims files were erroring out of the intake pipeline at a supplemental-benefits business — and the audit tables had no record of the failures. Files were arriving. Some of what was in them was not being processed. And nothing in the system was keeping score.
I started with a bounded sample. The number of claims expected and the number accounted for did not agree. That gap was too specific to dismiss as noise, so I proposed extending the analysis.
The investigation identified claims and provider payments that needed resolution. Timely payment was a business and compliance concern. The important finding was that completed-work reporting had not made the missing population visible.
Recovering the claims addressed the immediate issue. But recovery was not the whole product. I helped make received-versus-processed reconciliation visible through an audit view and reporting in Tableau, with operational ownership and leadership review. The next gap needed to be easier to find than the first.
Separately, I led the replacement of Microsoft BizTalk with homegrown EDI shredding directly into a normalized datamart before adjudication. Capturing complete claim data reduced enhancement turnaround by 50% and improved received-to-paid mapping and CMS reporting. The LifePRO engine replacement, daily reconciliation and paper-to-EDI conversion were separate projects. Provider identity resolution was separate as well.
I think of this as the chapter where I learned that a missing audit trail is a finding, not a gap. If a system cannot tell you what it dropped, assume it dropped something.
Tools and methods referenced in this chapter EDI 837 · Microsoft BizTalk · homegrown EDI shredding · normalized datamart · reconciliation logic · Tableau · received-to-paid mapping · CMS reporting.