A Company/University Joint Venture to Build a Knowledge-Based System

A joint venture between a university-based research institute and a health insurance company to build a knowledge-based system to perform medical review of health insurance claims is described. In an early format test, the system made appropriate decisions for approximately 70% of the claims. The remaining claims were referred to human reviewers in accordance with company policy. Forming a joint venture proved to be a reasonable cost alternative to distant and more expensive consultants. The article examines the impact of the differing cultures of the company and the university on the cohesion in the joint knowledge engineering group. It also examines the current literature on the development cycle for building knowledge-based systems as the framework for analyzing the events in this project, particularly the influence of the claims review task on system design. From another perspective, it examines participant roles in terms of shifts of attention among domain knowledge, knowledge representation, system performance, and the kinds of skills needed to improve the evolving system. The conclusion includes a series of recommendations that may assist other companies and universities setting up similar joint ventures.