Data Mining Driven Rule Based Expert System for Medical Billing Compliance: A Case Study

Data Mining Driven Rule Based Expert System for Medical Billing Compliance: A Case Study

Umair Abdullah (Foundation University, Pakistan), Aftab Ahmed (Foundation University, Pakistan), Sohail Asghar (COMSATs Institute of Information Technology, Pakistan) and Kashif Zafar (National University of Computer and Emerging Sciences, Pakistan)
DOI: 10.4018/978-1-4666-8513-0.ch013
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Most of the data mining projects generate information (summarized in the form of graphs and charts) for business executives and decision makers; however it leaves to the choice of decision makers either to use it or disregard it. The manual use of the extracted knowledge limits the effectiveness of data mining technology considerably. This chapter proposes an architecture, in which data mining module is utilized to provide continuous supply of knowledge to a rule based expert system. Proposed approach solves the knowledge acquisition problem of rule based systems and also enhances effective utilization of data mining techniques (i.e. by supplying extracted knowledge to rule based system for automated use). The chapter describes the details of a data mining driven rule based expert system applied in medical billing domain. Main modules of the system along with the final analysis of performance of the system have also been presented.
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Problem Statement

Raw data – of any application domain – coming from multiple heterogeneous sources need to be processed for the implementation of business rules according to the business need/logic. Implementing business logic with the help of conventional programming techniques is not feasible. Proposed solution for the implementation of business logic is in the form of a Rule Based System (RBS) module integrated with main data processing software.

Domain experts having knowledge of business rules coordinate with RBS developers for the editing, debugging, updating and management of rules. This coordination requirement leads to the problem of inefficiency in operational process. Knowledge editor – a Graphical User Interface (GUI) based front end – is the proposed solution for the problem of developing, editing, debugging, updating and managing the production rules of RBS. Domain experts with the help of easy to use knowledge editor may do all the rule related tasks by themselves. However, knowledge engineers (i.e. domain experts) using knowledge editor for management of rules can only develop those rules for which they have knowledge.

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