AdjudiPro Overview

AdjudiPro Overview : 

AdjudiPro Overview

Application Overview : 

Application Overview

AdjudiPro is… : 

AdjudiPro is… AdjudiPro is a batch-mode UNIX-based client/server, knowledge based system (i.e., expert system) that operates in tandem with COSMOS. Its goal is to improve UHG's claims adjudication process (i.e., determination of proper payment). AdjudiPro pulls open claims from COSMOS, adjudicates them using an AI engine, writes the results back to COSMOS, and generates daily reports of its activity. In addition, it generates data to support cost-savings statistics and the interactive lookup of claim resolution

Common Considerations : 

Common Considerations The development/maintenance effort is currently focussed on: Ø Implementing the regulatory changes as prescribed by AMA, HIPAA, ASA and other accredited institutions in the health care industry. Ø   Fixing the production problems reported. Ø   Enhancements to the review business logic.

Languages : 

Languages Following are the development languages that have been used for AdjudiPro application and development tools: Ø C - All of the AdjudiPro servers were written in C. All processing with the exception of the expert system AI code is written in this language. Ø Korn - Korn is a shell scripting language that is used extensively for development tools and tools for running AdjudiPro. The scripts that start AdjudiPro, produce reports, and allow us to test were originally written as korn shell scripts. Ø SNAP - Snap is our expert system language. It holds all of the rules that make up AdjudiPro.

Sybase Databases : 

Sybase Databases AdjudiPro currently uses three Sybase databases for its processing: Ø  The working database stores all the information that is required for a AdjudiPro run including the reviewable claims list, sites, reviews applicable for each site, name of the knowledge source for a specific review etc., Ø  The AUI database that is used by AdjudiPro to write its adjudication results. The database was intended to be used by the AdjudiPro UI that is no longer in use today. The database has been retained because it interfaces and generates the data stored by the third database. Ø   The Cost savings database stores the cost savings realized by having AdjudiPro process the claims. The cost savings information is generated by the stored procedures on the AUI database. The database is used to generate management reports for the cost saved by site, product, review etc., These reports are generated once in a month for the period (start of the current quarter to end of the current month).

Functionalities : 

Functionalities

Reviews : 

Reviews Claims processor reviews - Claims processors are responsible for administrative types of reviews, such as verification of pre-authorization or referral. Medical analyst reviews - Medical analysts are RN (Registered Nurse)s. This group is responsible for reviews that require clinical training and experience. Reviews processed by this group include determination of whether or not a submitted service is cosmetic or experimental. Ø AI reviews - A review is considered an AI review AdjudiPro is setup to process that review. AdjudiPro may change the claims by denying lines or just clear the review for most claims and send the rest to manual review. It depends upon what the business wants AdjudiPro to do.

History Filters : 

History Filters Adjudication of a particular claim requires information on other claims submitted by the same member to determine the appropriateness of the services being claimed. This information is loosely termed as ‘history’. For AdjudiPro, history refers to lines on another claim or sub-audit that are related somehow. To understand the implication of the term “history”, consider the following example: Example 1 Consider the following two claims: Audit Number: 28043075-00 Audit Number: 28043075-01 Member: 10310-123456789-02 Member: 10310-123456789-02 R1 01/01/2001 H1 01/01/2001 R2 01/01/2001 H2 01/01/2001 R3 01/01/2001 H3 01/03/2001 R4 01/01/2001 H4 01/03/2001

History Filters : 

History Filters The criteria in the history control file can be based on the following attributes: Date of service (A period from a predefined number of days before the DOS of the line on review and after the DOS of the line on review). Amount paid/Member eligibility for the history line. Set of procedure codes Set of procedure modifiers Same or different providers. Place of service. History filter information is maintained in a set of configuration files.

First-In Claims : 

First-In Claims As a general rule, claims should be processed in the order in which they have been received. When processing the claim on review together its associated history, AdjudiPro applies the following rules to determine which is the first claim. Ø       If the received date of one claim is greater than the other, then the latter is considered as the ‘First-In claim’. Ø       If the received date of two claims is same and the audit number of one claim is greater than the other, then the latter is considered to be the ‘First-In claim’. (ie., the claim that was first entered into the system was considered to be the first claim since the audit numbers are auto-generated). Ø       If the received date and audit numbers of two claims are same and sub-audit number of one claim is greater than the other, then the latter is considered to be the ‘First-In claim’. (ie., the claim that was first entered into the system was considered to be the first claim since the sub-audit numbers are auto-generated).

Lists : 

Lists Certain information required for processing of the claims are stored as Lists external to the application code. For instance, a particular review requires to know whether a particular CPT code has been categorized as PPMC (Procedure/Pain Management Code) or not. Based on this information, AdjudiPro will decide whether to pay the procedure or not. This information is stored as a separate list containing all the CPT codes that have been categorized as PPMC codes. The reason for externalizing this information is that such categorizations change frequently and changes to the list should be effected without making any change to the application code.

Bundling : 

Bundling Another common scenario in adjudication is to consider a set of procedure codes performed within a time frame as bundles and reimburse only one of them at 100% of the charges. This concept is called Bundling. For the application to process this information, it needs information on procedure codes that can be considered as bundles.

Service Request Handling : 

Service Request Handling

Types of Service Request : 

Types of Service Request The AdjudiPro development team is responsible for handling three types of service requests, namely, Ø       AdjudiPro service requests(ASR) Ø       Peregrine Problem Reports Ø       Cost Savings Reports.

ASRs : 

ASRs There are three different types of ASRs that are currently recognized: Ø       Enhancements: Enhancements typically require change to the AdjudiPro application code to implement the service request. Example: Modification to review logic. Ø       List Changes: These service requests require a modification to the external lists that are referred to at the run time. They do not require any code changes and such updates happen as part of the yearly policy updates for the different reviews. Ø       Production Problem Request (PPR): These requests are originally reported as production problems in the implementation.

Peregrine Problem Reports : 

Peregrine Problem Reports These reports are questions about the adjudication logic applied by AdjudiPro when processing a specific claim. It is the responsibility of the on call production support person to resolve these problem reports and provide an explanation on the processing logic for the specific claim

Cost Savings Report : 

Cost Savings Report Cost saving reports provide a summary of cost savings realized by allowing AdjudiPro to verify the accuracy of the claims submitted. The cost savings is reported on several dimensions including the financial product, COSMOS site, Review processed by AdjudiPro, Advice recommended by AdjudiPro etc., The reports have already been developed as cubes using the Cognos BI reporting tools. They have to be run every month on the 10th day and the results have to be published onto the corporate web site. The monthly reports include: Ø       Financial product level savings for all the divisions put together. Ø       Review-wise savings for each of the divisions.

System Functions : 

System Functions

AdjudiPro runs…. : 

AdjudiPro runs…. Six times a day, an AdjudiPro "run" is initiated. Each run consists of two basic steps: Ø  The retrieval of the list of reviewable claims - The Reviewable Claims List contains all physician claims on COSMOS where the next open review is an AI review. Any claims where AdjudiPro has already processed the open review that day and sent it to manual review are removed from this list. The processing of those claims

Claim Processing Flow : 

Claim Processing Flow

Review processing : 

Review processing For each review, the following steps take place:   Ø      A request for adjudication of the claim is made to the review's knowledge server. If an error occurred during this process, the error is reported to the report data server regarding the error. Ø    If the adjudication result indicates that manual review is required, a time stamp for the claim and review is updated on COSMOS to prevent the claim from being processed for that review again on the same calendar day. Ø    If the adjudication result is to clear the review: o        The review is cleared on COSMOS. o        Any necessary history adjustments are reported or performed, depending on whether the site is configured for automated adjustments. o        If the review is UBH, the units used are updated on COSMOS. o        If the review is No Fee Max, payment history report data may be recorded in a local Sybase table for use in quarterly reports. o        If history adjustments or recording took place, cost-savings information is recorded in local Sybase tables for use by the daily Automated Cost Savings (ACS) program. Ø    The adjudication results and relevant history are reported to the report data server.

COSMOS Screens : 

COSMOS Screens

Commonly Used COSMOS Screens : 

Commonly Used COSMOS Screens

QUESTIONS? : 

QUESTIONS?

Thank you! : 

Thank you!