Expert Systems in the Insurance Industry. Uses of Expert Systems in Insurance Underwriting Policy...
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Transcript of Expert Systems in the Insurance Industry. Uses of Expert Systems in Insurance Underwriting Policy...
![Page 1: Expert Systems in the Insurance Industry. Uses of Expert Systems in Insurance Underwriting Policy Matching Benefit Querying Claim Processing.](https://reader035.fdocuments.us/reader035/viewer/2022062515/56649d2a5503460f949fe82e/html5/thumbnails/1.jpg)
Expert Systems in the Insurance Industry
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Uses of Expert Systems in Insurance
• Underwriting
• Policy Matching
• Benefit Querying
• Claim Processing
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BenInqA Benefit Inquiry tool
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BenInq
• helps customer service representatives determine what medical services a customer is covered for
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Why?
• Insurance companies have many products
• Better searching
• More detailed information
• Easier to modify
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How It Works
• Knowledge representation
• Rule Representation
• Reasoning Methods
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Knowledge Representation
• Services
• Benefits
• Coverage– Business Rules
• Cost sharing• Access• Administrative and Medical
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External Representation
• Both Services and Benefits are organized in semantic networks
• Services are organized in a multiple-inheritance hierarchy
• Benefits are shown by using ‘covered’ and ‘excluded’ links between benefits and services nodes
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Internal Representation
• Represented as a Formula-Augmented Semantic Network (FAN)
• A FAN allows us to attach rules to nodes using well formed formulae
• These rules allow us to apply regulations to each of the nodes
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Internal Representation
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Rule Representation
• Rules are represented using well-formed formulae
• translates to: Patients in Drug Rehabilitation programs lose all rehab benefits for one year if they are non-compliant
Drug-rehab(p) enrolled(x,p,i) j sub(j,i) non-compliant(x,p,j) ((Drug-rehab(p2) enrolled(x,p2,i2) time(start(i2)) – time(end(j)) < 1year) ~covered(x,p2))
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Reasoning Methods
• Determining if a service is covered or excluded by a benefit
• Determining which rules apply to a node
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Reasoning Methods
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Reasoning Methods
• Well-Formed Formula Inheritance problem– Since nodes can inherit from
multiple parents which rules apply?
• Maximally Consistent Subsets (mcs)
• Preferred Maximally Consistent Subsets (pmcs)
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PMCS
• First remove conflicted and pre-empted edges
• Then, starting at the focus node traverse upwards
• At each node take the pmcs of the set computed so far and the wff’s at the current node
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Implementation
• System comprises of two tools– inquiry tool– authoring tool
• Implemented using VisualAge Smalltalk
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Usage
• Two main user groups– Customer Service
Representatives (CSR’s)– Policy Modifiers (PM’s)
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CSR’s View
• Shows services, coverage information, and rules
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PM’s View
• Can add new benefits, modify services and benefits, or delete products
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Evaluation
• Users found the system very user friendly and required little to no training
• PM’s however did have one issue: modifying or adding wff’s was difficult
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Colossus
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What is Colossus?
• Used in claims processing
• Injuries are classified according to 600 injury codes
• Using this information it provides an amount to cover the damages the person suffered
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Why?
• A GIO study found that there was a standard deviation of 80% for the same claim by different assessors
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How it works
• Assessors are asked up to 700 questions (usually less)
• The system compiles the information from the questions into 5 categories
• The system combines the 5 categories into a percentage value
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Issues
• There are 3 variables which affect how Colossus reaches its recommended figure– Interpretations of the facts by
assessors– How Colossus uses the data
to construct the 5 categories– The algorithm to combine the
categories into a percentage
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Results
• After implementing the system GIO found that the standard deviation for claims dropped from 85% to 15%
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Use
• Originally used by GIO of Australia
• Colossus also is used by 13 of the top 20 US Property and Casualty insurers
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Bibliography• 1) Morgenstern, L., Singh, M., An Expert
System Using Nonmonotonic Techniques for Benefits Inquiry in the Insurance Industry, Proceedings of the Fifteenth International Joint Conference on Artificial Intelligence
• 2) Morgenstern, L., Inheriting Well-formed Formulae in a Formula-Augmented Semantic Network, KR'96: Principles of Knowledge Representation and Reasoning
• 3) Greenleaf, G., A Colossus come to judgement: GIO’s expert system on general damages, Law & Information Technology column, Australian Law Journal 26 November 1992