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Understanding health insurance rules isn't just something that perplexes patients, doctors and hospitals - it can stump health insurance companies themselves and even their computers.
The enormous number of diagnoses, medical procedures and rules for paying for them are what make processing claims difficult for insurers, according to officials of IntelliClaim Inc., a six-year-old Norwalk company created to help insurers sort through the flow.
"Their ability to come up with creative plan designs exceeds their ability to administer them," said Akshay Gupta, chief marketing and business development officer. "And then they have under-invested traditionally in IT (information technology). That's how people like us exist."
An analyst of the health insurance industry says it's not worthwhile for most insurers to master the complexity of the process, creating a niche for companies that specialize in mastering it.
Robert Booz, vice president for health services research at Meta Group Inc. of Stamford, said all but very large health insurers find it difficult to master all the decisionmaking for claims payments - or even to create software to do it for them.
"The value proposition for what we do for insurance companies is very dramatic," Gupta said. "The impact we have on the bottom line is sufficient to cause a difference in their earnings per share. So no one asks us to go away because of the level of impact we can produce."
IntelliClaim's growth has been dramatic as well. In 2001, the company's revenues went up 50 percent over the year before, in 2002 the rise...