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Errors in Health Care Claims Processing The Health insurance company conducted an intensive investigation of the entire claim's submission and payment process. A team of
Errors in Health Care Claims Processing The Health insurance company conducted an intensive investigation of the entire claim's submission and payment process. A team of key personnel was selected from the claims processing, provider relations and marketing, internal auditing, data processing and medical review departments. Based on their experience and a review of the process, the team members finally agreed on a list of possible errors. Three of these errors (procedure and diagnosis codes, provider information and patient information) are related to the submission process and must be checked by reviewing patients' medical records in clinics and hospitals. Three possible errors (pricing schedules, contract applications and provider adjustments) are related to the processing of claims for payment within the insurance company office. Programme and system errors are included in the category "others." A complete audit of a random sample of 1000 claims began with checking each claim against medical records in clinics and hospitals and the proceeded through the final payment stage. Claims with errors were separated and the total number of errors of each type was recorded. If a claim had multiple errors, then each error was recorded. In this process many decisions were concerning error definition. The table below represents the frequency distribution of the categories and the number of errors in each category: (a) Based on the data in the data above, construct a pareto diagram. [10 marks] (b) Explain the diagram. [5 marks]
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