Oracle, Spring, Hibernate
Area of focus
Claims and Billing
Medical Charts Review App
Web-based workflow app for efficient and automated medical charts review for the detection of duplication and fraud.
The main objective of this project was
to create a Health Care Reform (HCR)
compliant solution that would enable
review of a larger volume of claims.
The technical issues that the payer
was experiencing were large
numbers of records that needed to
be processed and highly complex
logic for automated compassion and
discrepancy detection. The client’s
original estimate was that 10,000
records would be handled in a given
day. Revised estimates later put that
figure at upwards of 1,000,000 records
per day. In order to accommodate this
spike, we recommended a different
approach to record retrieval by
leveraging web services.
The biggest risk that Vicert faced was
the CMS mandated requirements and
a constantly changing interpretation
of those requirements by the client.
Significant changes to the end
requirements meant that managing
the delivery of the app components
to allow maximum flexibility for those
necessary changes was critical.
The three main problems that the
client was trying to solve are as follows:
• Centers for Medicare and
Medicaid Services (CMS) Mandate
This mandate required the review
of claims submissions for payers
requesting reimbursements for
balanced payments through the
Health Care Reform legislation.
• Health Care Reform (HCR)
Existing solutions didn’t meet the HCR
requirements, so the risk team made
the decision to implement a new
solution that would satisfy them.
• Manual Claims Processing
The amount of claims that could be
processed using the legacy process
(manual spreadsheets) was small.
That is why an automated solution
was needed to filter the majority
of suspected fraudulent claims for
manual human review
Vicert created a centralized medical
chart repository for storing electronic
versions of the medical charts
of identified members with risk
adjustment. The workflow app we
developed required that we build a
complex set of logic based on CMS
requirements to identify potentially
fraudulent cases and then integrate
the cases to two external solutions for
chart and claims data. This allowed
staff to manually review those specific
cases. Any updates made by staff had
to then be stored and transmitted to CMS using their standard format.
From a technical standpoint, the
key elements of the solution were
a Java web-based app with Spring
and Hibernate frameworks. The web based solution is flexible, secure
and scalable. The solution includes
a configurable workflow, enabling
automated indexing and processing
of medical charts. Vicert implemented
integration with third-party vendors,
Epi Source and Record Flow. These
vendors were used to automate chart
retrieval and processing.
The health payer gained the ability to
process and review all claims charts
instead of the previous manual process
which included only 5% of the total
number of claims. The solution enabled
automated processing and evaluation
of these claims charts, with only a small
subset of records for manual review. In
the long run, the decision to develop
this solution has significantly impacted
their workflow and increased ROI.