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Health Claims Processing Workflow

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Prepared by

Laurence J. Best (American Management Systems, Inc.)


The Design Problem

Use Cases


A health claims processing organization is commissioning a system that routes work between the various components of its health claims processing operation. Such organizations, found throughout the world, reimburse health care providers (e.g., doctors and hospitals) for medical treatment. These organizations are sometimes government agencies and sometimes insurance companies. There is often a requirement for insurance company processing even in countries with socialized medicine; for example, Canada's national health care system does not encompass routine dental and vision care.

The workflow system to be created routes work objects (in this case, health claims and supporting documentation) among the major processing components of the organization. Some of these processing components are highly automated, while others require quite a bit of human judgment, but all components have some level of computer system support. It is not the objective of the new workflow system to replace any existing components, but rather to improve the overall movement of claims through these components.

The major components of the particular health claim processing operation that will be linked by the new workflow routing system are as follows:

  1. Receipt processing. This consists of various systems which receive health claims and supporting documents via a variety of different sources. Claims are received electronically, for example, from claims clearing houses, Health Maintenance Organizations, and some physicians. They are also received "electronically" via Fax. Finally, paper claims are received via mail. All are logged by assigning a unique identifier. Paper claims and supporting documents are scanned.
  2. OCR. Scanned paper claims and fax files are processed via an ICR (Intelligent Character Recognition) process to determine what kind of document it is. Each document is then subjected to form dropout whereby standard form lines are eliminated), deskewing (to right the image), and despeckling (to eliminate random scan errors). The image is then run through an OCR (Optical Character Recognition) process to capture the data associated with each form field.
  3. Repair and committal. Fields with sufficiently low confidence levels are subjected to a manual repair data entry process. If necessary, the document is rescanned. In addition, certain types of claims images that cannot be processed by OCR are transmitted to an offshore data entry vendor (for example, in the Dominican Republic or Barbados) for keying, and keyed data transmitted back. Finally, all images are committed to optical disk and logged into an index database, and claim data loaded to a mainframe-based claims payment system.
  4. Provider/Plan match. An automated process continually attempts to match the plan (i.e., the contract under which the claim is being paid) and the health care provider (i.e., the doctor) identified on the claim with the providers with which the overall claim processing organization has a contract. If there is not an exact match, the program identifies the most likely matches based on soundex technology. The system displays prospective matches to knowledge workers in order of the likelihood of the match, who then identify the correct provider.
  5. Auto adjudication. The claim payment system determines whether a claim can be paid, and how much to pay, if there are no inconsistencies between six key data items associated with the claim. If there are inconsistencies, the system "pends" (i.e., suspends) the claim for processing by the appropriate claims adjudicator, depending on a number of factors including the plan type, the type of treatment involved, and the amount of work in each adjudicator's work queue.
  6. Adjudication of pended claims. The adjudicator can access the mainframe system for a claim history or the image system for an image or, for electronic claims, a fabricated representation of the original claim. The adjudicator either approves the claim for payment, specifying the proper amount to pay, generates correspondence requesting additional or clarifying information, or generates correspondence denying the claim. Text processing is supported via link to a standard word processing package.

The Design Problem

Design a work routing system that routes health claims through the various stages of the adjudication process. The major responsibilities of the system are to:

  1. account for work objects at all times (ensuring that all are processed on a timely basis),
  2. present work performers (the workers and information systems involved with the process) with work objects at the earliest appropriate time,
  3. inform process managers of process anomalies,
  4. provide a means for process managers to adjust the work process, and
  5. provide management information on the overall work process.

The system must not "hard code" routing rules; instead, it must provide the means for initially defining a "default" work process, with the capability of adjusting this process for individual items should the need arise.

Use Cases

Use Case #1: Adjudicator selection of next work item

The adjudicator retrieves items from the work queue on either a "pull" basis by selecting a particular claim (perhaps based on special instructions from a supervisor) or a "push" basis, by having the workflow system provide the most appropriate claim to process next, based on a work prioritization algorithm. This work prioritization algorithm is not "hard-coded;" the workflow system provides a means for the system administrator to define and modify this algorithm. (Note - designing the facility for defining the work prioritization algorithm is outside of the scope of this exercise).

Use Case #2: Process management

The process manager modifies routing rules for a Dental claims, one of a number of claim types. The new rules are largely based on the "default" process for all claims, with certain processing differences. The process manager has the option of having the new routing rules apply only to newly received claims, or to claims already being processed. The system automatically identifies any claims that have reached a state under the old process that is inconsistent with the new process.

Use Case #3: Work item reconcilement

The system administrator access the workflow system to determine whether all work objects are accounted for. The workflow system reconciles the system based on counts of the number of work objects outstanding in the various stages of the process as of the last synchronization point (midnight local time), the number of work objects received since that point, and the number completed since that point.

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