Healthcare documents · 24 of 31 · Evidence · 3 minutes
Healthcare products. From problem to production.
Actions from metrics
Claims automation, provider matching and a legacy claims integration replaced — explored through the documents and decisions.
01
From a metric movement to a product action: the match rule
Operations wanted to drop a provider-matching rule because some of its matches were wrong. I measured what removing it would do before agreeing.
Product decision
Change the cause, not the rule that exposes it.
- Document type
- Actions from metrics
- Lifecycle stage
- Operate & learn · 17 / Operate & learn
- Contents
- 3 sections · 1 table · about 1 min
- Status
- Sample format · headline results from my healthcare claims work
- Product decision
- Change the cause, not the rule that exposes it.
Portfolio sample from my healthcare product experience. Requirements, thresholds and review records are illustrative; they are not employer documents or historical sign-offs.
The signal
Provider matching used national provider identifier plus tax identifier to link a claim to a provider record. Some matches were wrong, and operations asked to remove the rule.
- national provider identifier plus tax identifier to link a claim to a provider record
- Some matches were wrong
- operations asked to remove the rule
Analysis to action
I analyzed a month of claims with and without the logic. Removing it would have created tens of thousands of extra manual fallouts. The wrong-match cases were real but far smaller. The right action was to fix identity at its source: a proof of concept matched 30,000 providers against the enterprise provider master and matched 29,870, or 99%, which won funding to move provider matching onto the master and retire the legacy matching.
| Signal | Question | Action |
|---|---|---|
| Wrong matches from the rule | How many, and what does the rule prevent? | Measure a month with and without the rule |
| Tens of thousands of extra fallouts without the rule | Is the rule the cause or the detector? | Keep the rule; fix identity at the source |
| 99% match against the provider master | Can the master replace legacy matching? | Fund the migration; retire legacy |
Roadmap implication
Identity, reconciliation and claim-file shredding were distinct projects. 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.
- Identity, reconciliation and claim-file shredding were distinct projects
- homegrown EDI shredding directly into a normalized datamart before adjudication
- reduced enhancement turnaround by 50% improved received-to-paid mapping and CMS reporting