Full Stack: Java, jQuery, Oracle
Area of focus
Claims and Billing
Medical Charts Review App
A flexible, secure and scalable web-based solution that automatically reviews 100% of claims, filters suspected fraudulent ones for the manual review, and facilitates CMS and HCR compliance
Our client identified a need to create a new web-based tool for facilitating the medical chart review process.
Those files are scrutinized to ensure that payments are based on reliable and accurate records from physicians and facilities.
This new tool needed to be able to quickly process many claims while applying a highly complex logic for automated compression and discrepancy detection.
The main problems our client needed to solve:
- The CMS mandate required the review of claims for payers requesting reimbursements for balanced payments through the Health Care Reform (HCR) legislation.
- Needed to meet the HCR requirements in full.
- And replace a legacy, manual process with the automatic reviewing of all claims (instead of only 5%) and auto-filter suspected fraudulent claims for manual review
The team overcame the complexity of the CMS-mandated requirements by tightly managing the delivery of app components while allowing maximum flexibility for necessary changes.
One example of those changes was related to the number of claims to be processed per day. The client’s original estimate was that 10,000 records would be handled on any given day, but revised estimates later put that figure at more than 1,000,000 records per day. In order to accommodate this spike, we have recommended and implemented a different approach to record retrieval by leveraging web services, which was not planned originally.
Vicert created a centralized medical chart repository for storing electronic versions of the medical charts identified for risk adjustment. The solution stores both the medical charts in PDF form and the medical chart data parsed from the text files, provided by the coding vendor.
The workflow we have developed applies a set of complex rules based on the CMS requirements to identify potentially fraudulent cases, ties those cases with their corresponding chart and claim data, and sends those specific cases to our client’s staff for manual review. Any updates made by the staff are then stored and transmitted to CMS using their standard format.
From a technical standpoint, the solution is built as a Java web-based app using the Spring and Hibernate frameworks. It supports role-based user authentication and authorization. The workflow is fully configurable, enabling the automated indexing and processing of medical charts.
Vicert implemented a bi-directional integration with two third-party vendors: Epi Source and Record Flow. The application provides a full set of reporting capabilities, including various daily reports, inventory statistics, and individual case summaries.
- The web-based solution we built is flexible, secure, and scalable. The health payer gained the ability to process and review all claim charts instead of only 5% of the total number of claims.
- The solution enabled the automated processing and evaluation of the claim charts, with only a small subset of records being sent for manual review, thus significantly decreasing the time and effort needed from the client’s staff, and improving the quality of the review itself.
- The decision to develop a solution from scratch instead of buying off-the-shelf has proven to be the right one for our client.
- Vicert’s flexibility during implementation meant that they have gained a solution that fulfills all of their requirements from the moment of deployment, bringing a quickly-increasing ROI.