Case 01
Reconstructing information that existed at first notice
In 2023 Soravane reviewed a proposed first-notice triage evaluation built from 120000 historical claims. The analytical file was convenient because it combined information eventually held for each case. That convenience was also its weakness. In 18000 records, settlement fields had been entered after first notice. A replay using those fields could appear to anticipate a development that the original decision-maker could not yet have known.
Emi Tsurahana asked when the fields became available, rather than whether the values were correct in the latest file. The delivery sponsor wanted to retain the initial evaluation because it offered a concise demonstration of progress. I understood the cost of rebuilding the account, but the historical decision point was essential to the question. Accurate later information was still unsuitable as an earlier input. Removing the most obvious settlement label without checking related fields would not have settled that problem.
I chose to withhold the original performance claim and reconstruct the eligible inputs for each historical first-notice point. JPY 310 million supported the review and data work. We kept later outcomes where they were needed to describe what subsequently happened, while distinguishing them from information permitted as inputs to the earlier decision. The claims function retained responsibility for handling decisions, and the analytical owners remained responsible for a properly specified evaluation after the data reconstruction.
What we gave up was the immediate use of a persuasive retrospective result. The delivered output was an inspectable input history and a revised basis for evaluation, not a replacement score or proof of a service improvement. I did not describe the 18000 records as fraudulent or unusable for every purpose. The issue was their suitability for a particular time-dependent question. My responsibility was to prevent a completed file from giving the institution an unrealistic impression of what it could have known when the claim first arrived.