Medical Informatics
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Medical Informatics
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What to do about the Department of Veteran Affair’s Continued Backlog of Claims? By Michael Glass, CEO Medical Informatics, Inc. Like many other veterans, I have puzzled over the inability of the VA to reduce the backlog of Veterans’ disability claims for more than a decade. Each newly appointed Director for the Veterans Administration pledges to attack the backlog as their number one priority. And to be fair, with significant increases in funding the VBA has hired almost 20,000 new claims processors over the past 18 month to reduce the claims backlog. But the backlog remains and has grown this past year. This is due in part to an increased number of claims from Vietnam War vets who are aging and discovering medical problems that they believe are service related and to low productivity of newly hired claims processor. While a significant number of new claims processors have been hired and trained, they have yet to gain the proficiency needed to evaluate the claims submitted by veterans. This lack of productivity in the face of hundreds of millions of new funds at a time when Congress is dealing with record deficits has forced the VA to look internally and externally for new approaches that might yield more immediate results. While the VA must be applauded for being open to trying new ideas, the innovation awards given to the VA staff has done little to eliminate the claims backlog. Some in Congress believe that the VA claims process is broken and that providing additional resources to address this problem without wholesale changes is throwing good money after bad. Without focusing on why all the attempts to date have little impact on the claims backlog, it is time to step back and look at the functional requirements of the claims system and then identify proven technology which may fit the unique requirements of the VA. The claims system should deliver accurate assessments of applicants service related disabilities, must be reliable, repeatable and to the greatest extent possible, must convert qualitative into quantitative measures. The VA has taken considerable efforts to improve the quality and consistency of claims evaluations. Reducing/eliminating regional and processor bias is an ongoing battle that precipitated the STARS program for quality measurement. Current Disability claims rating decisions depend on the individual decisions of VBA Raters. Performance will be impacted by: (1) the quality and relevance of medical information, (2) accuracy and ease of use of information systems, (3) training and experience of raters, (4) effectiveness of the quality review system, and (5) number of raters and other personnel involved in the claims adjudication process. Given this backdrop, what are commercial insurance providers using to perform their claims processing? While commercial claims are much different in their makeup, the challenges insurance companies faced 10-15 years ago before most of the claims systems were converted to HL-7 EDI, are similar to those currently facing the VBA. First the volumes of paper that had to be processed each day by each processing center were tens of thousands to millions of pages per day. Managing and sorting this volume of paper demanded hundreds of staff and millions of dollars. The industry discovered that digitizing the claims and their attachments, converting them to machine readable data for and electronic sorting dramatically reduced the time to process a claim from weeks to days. Coding of the claims for payment using standard fees for medical procedures (ICD-9) resulted in further cost and time reductions making it possible for the majority (90%+) of claims to be processed in a single day. This dramatic improvement was brought about by developing rules for the processing of each claim type and yielded an unimagined reliability in the claims process. Claims processors were able to go from 2-5 claims an hour to 250-500 claims an hour with many more claims being processed without being touched by a human hand. There was no single “silver bullet” or magical answer but all systems had several common elements: · All used optical character recognition (OCR) to convert raster images to machine readable data · All used rules engines within their workflows to “scrub” the claims prior to presentation to their claims processing and payment systems · Constant modifications to their rules engines were needed due to changes in either the ICD coding structure or negotiated group insurance costs In the past 15 years since this process was first introduced, technology has continued to improve. OCR engines now use multiple sources and when handprint and/or script is encountered, Intelligent Character Recognition (ICR) can be used to convert raster data to machine readable data. By converting the voluminous claim files to digital documents, full-text engines can be used in conjunction with coding systems to identify medical problems and dates or occurrence. Accuracy, reliability and repeatability can all be dramatically improved by using common medical dictionaries along with workflow rules to determine the level and type of disability evidenced by the submission. Computers can “read”, sort, organize and analyze a claim in the same time it takes a claims processor to read a claim summary. While the VBA has been scanning claims for many years, the quality and rigor needed in this process in order to convert the images to machine readable information is significant. Using the latest OCR/ICR techniques, in combination with rules based workflows, and coding systems with common medical terms should yield dramatic and almost immediate results at a small fraction of the cost of the 20,000 new claims processors who continue to struggle today. The technical answer is readily available and affordable if the VBA wants to dramatically improve the quality and timeliness of the disability claims process. Why hasn’t the VA pursued a pilot program with one of their current vendors who may have experience in these technologies? The answer to this eludes us but it may be that they are so busy struggling with day to day issues that they can’t see the forest for all the trees in the way. While the promise of a higher quality of care is a goal that most residents of Indiana would probably agree is a worthy achievement I am wondering at what cost? The HITECH Act was to stimulate investments in healthcare that would significantly reduce the cost of care, particularly for the government supported programs of Medicare and Medicaid. I fail to see how the exemplar offered by IHIE, which increased support jobs by 2500 and revenue of $202 million as they were delivering a fee-for-service to physicians on quality reporting and patient data, which according to their own pronouncement, is not scrubbed in any way is reducing the cost of care. The investments in Accountable Care Organizations are focused on moving from the old transaction based, fee-for-service model to one of total collaborative care. The data submitted to IHIE is taken “as is”. Only the patient name-ID receives attention so that the match from various sources (labs, physicians, hospitals, etc.) can be aggregated for patients. This highly touted health exchange does seem to provide a means to exchange machine generated information. Though laudable, the majority of the clinical (historical) information resides in the patients’ physical medical record; radiographs, CT scans, and other imaging procedures, can’t be transmitted or exchanged via this network. It appears, that much akin to the clamor when S. Morse sent his first message via the telegraph to a distant colleague, this proclamation of successfully communicating health care machine generated data is a bit anti-climactic when one is expecting exchange of DICOM images, PACS images, mammograms and full motion video. Michael Glass CEO GlassEye Consulting FOLLOW THE LINKS BELOW GlassEye Consulting- i-Sight Case Management Overview.pdf |
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