Managing provider networks through expert systems: use of patterns of treatment to address overutilization

Among the most important contributors to rising health care costs is excess utilization of services. Sophisticated clinical criteria, encoded as an expert system in software, allow identification of probable excess utilization in large claims data sets. These systems can be used to adjudicate claims, resulting in direct cost savings, or to profile physicians and other providers, facilitating creation and maintenance of networks. These systems are used by traditional payers to promote quality, control costs, and enhance competitiveness and are beginning to be used by nontraditional payers, such as physician groups and hospital-based networks.