KAMEL: Knowledge Aware Medical Entity Linkage to Automate Health Insurance Claims Processing

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Automating the processing of health insurance claims to achieve "Straight-Through Processing" is one of the holy grails that all insurance companies aim to achieve. One of the major impediments to this automation is the difficulty in establishing the relationship between the underwriting exclusions that a policy has and the incoming claim's diagnosis information. Typically, policy underwriting exclusions are captured in free-text such as "Respiratory illnesses are excluded due to a pre-existing asthma condition". A medical claim coming from a hospital would have the diagnosis represented using the International Classification of Disease (ICD) codes from the World Health Organization. The complex and labour-intensive task of establishing the relationship between free-text underwriting exclusions in health insurance policies and medical diagnosis codes from health insurance claims is critical towards determining if a claim should be rejected due to underwriting exclusions. In this work, we present a novel framework that leverages both explicit and implicit domain knowledge present in medical ontologies and pre-trained language models respectively, to effectively establish the relationship between free-text describing medical conditions present in underwriting exclusions and the ICD-10CM diagnosis codes in health insurance claims. Termed KAMEL (Knowledge Aware Medical Entity Linkage), our proposed framework addresses the limitations faced by prior approaches when evaluated on real-world health insurance claims data. Our proposed framework have been deployed in several multi-national health insurance providers to automate their health insurance claims.