Simplifying Claims ManagementAlam SinghIII Workshop, Feb. 24th, 2012

Agenda

Key claims management objectivesStrengthening claim managementOptions for simplifying provider contracting & claims management Additional thoughts

Key claims management objectives

Claims management: key objectives

Detect fraudReduce transaction costTimely settlement of claimsReduce unwarranted excess payments & inappropriate billingDerive information for data driven contractingMonitor outcomes, promote provider transparency and accountability Promote customer involvement and awareness in managing claims

Common hurdlesResource mix availabilityAd-hoc operations / workflow processesNo standardisation in documentation, poor information exchange No or minimal provider contracting or agreementsMarket led packaged contracting rather than information based contractingMisaligned incentives in insurer TPA contractLack of common protocols / guidelines

Key success factors in claims management Full and complete exchange of information, efficientlyKnowing what to do with the information, efficientlyAligned incentives

Strengthening claim adjudication

Role of IT systemsDesirable features in claims management systemWorkflow management / process managementPolicy and insurance checks through rules engineICD Code specific processing checksIntegrated clinical logic (Example)Usual & customary charges checksProvider profiling

Ideally, system should aggregate benefit, beneficiary and claim information at single source (also referred to as policy, enrolment and claims data)Good rules engine with in-built logic key to auto-adjudication

Desirable features of IT systemsComponents required to achieve significant automation and reduce claims processing time.

Reduces claims processing time and simplifies claims personals work

Fraud management

Auto adjudication

Objective: Automation of claims processing, partially or fullyIntegrated rule engine or in-built logic can assist significantly if detailed data entry is done. Enrolment checks: verification, eligibility, benefits and coverageBenefit checks: sub-limits, person, policy, condition, procedure, equipment, facility and amount checks. Restrictions arising from underwriting (Example)Clinical checks: medical appropriateness, excluded services or items, known patterns of inappropriate billing (Example)Contracting checks: compliance with contracted or package rates. Can be additionally enhanced to check against usual & customary chargesPre-conditions: quality & granular data, standardized policy terms, pre-authorization & claims form. Computerised provider billing at line item level.

Standardizes claims management Save costs as excessive unwarranted items not missedImprove efficiency as clean claims can be paid quicklyImproves MIS and evidence based contracting with detailed bill entryOptimizes resource utilization as specialist resources used for specialist tasks

Requires high quality in-put data, including accurate coding (skill?)Can detect abuse but cannot easily detect fraud. Well structured fraud passes through auto adjudication engines. Most fraud in India is manually detected (MS Word printed bills, no lab reports or surgical notes, no telephone number for hospital , same handwriting on all bills, etc ).Advantages & disadvantages

Rules and clinical logic to identify variations*ICD CPT mismatch (indications not met for the diagnosis given at authorization)Delay in surgery flagLength of stay mismatchDuration of ICU stay mismatchExcessive physician visit flagUnwarranted specialist visit flagUnwarranted assistant surgeon fee flagProcedure not indicated for the age group / genderExcessive investigations flagUnwarranted investigation flagExcessive consumables flagUnwarranted consumables flagUnwarranted drug use flagDrug charged above marked price flagNon chargeable consumable flag. and more

*Data entry (capturing discharge details & bill)

Data Entry - (investigations)*

Adjudication screen

Milliman India Pvt. Ltd.Plot No. 121, Second Floor,Institutional Area, Sector 44, Gurgaon 122 022Haryana (India)Tel: +91 124 4641 503Fax: +91 124 4088 588alam.singh@milliman.com

Thank you

Some fields would get prepopulated from the authorization details in the system. If any information is overwritten (diagnosis or dates) it is flagged at the assessors variation screen. The option to add non listed options in the drop down as a text entry is available which gets flagged as not an expected entry for that diagnosis.The advantage of prepopulated fields or drop down saves time and minimizes errors in data entry. Some of the information sought here requires the availability of discharge summary (type of anesthesia, date of surgery etc)Expected usual entries heads get prepopulated here Doctor visits, room charges, investigations etc.. The ClaimsRef guidelines highlight the expected units for each of these entries based on diagnosis/ procedure or severity. The data entry person has to capture units in each line item. Subhead costs are captured. This can be expanded to include costs as well for each line item.

This assessor variation screen also flags;Excessive investigations flag if the units of investigations are more than expected for that diagnosis / procedure at that severityUnwarranted investigation flag If the investigation is not usually conducted for that diagnosis/ condition / severityExcessive consumables flag - if the units of consumables are more than expected for that diagnosis / procedure at that severityUnwarranted consumables flag If the consumable is not usual for that procedure / condition / severityExcessive drug use flag if the drugs administered are more than usual for that condition / procedure / severityUnwarranted drug use flag If the drug is not usual for that condition / procedure / severityDrug charged above marked price flag if drug price charged is higher than MRPPotential exclusion flag if the entry is a potential exclusion

The screen also provides access to the detailed guideline content and specifies specific checks / considerations for patterns of inappropriate billing for that specific condition / procedure.

The assessor may escalate variations to the provider for more information or deny, short pay or approve specific lines or the wole claim.