Medical Insurance Audit System – Businessware Technologies

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Medical Insurance Audit System

Medical Insurance Audit System
10%
Per-claim savings
60%
Claims with findings
3000+
Hospitals Covered
Anti-fraud control

There are many insurance companies employees and individuals can choose from while insuring themselves or their employees. The insurance company usually has multiple insurance plans where it describes what hospitals the person in trouble can access, what financial coverage it can offer and under what circumstances, state-specific conditions or even bonus programs for employers who purchase medical insurance for their employees in bulk.

When the client has undergone appropriate treatment after an accident, illness or other insured event, the hospital or other medical institution sends a bill to the insurance company. The insurance company studies the bill and attached documents very carefully because there is always a chance that something was calculated incorrectly or some circumstances were not taken into account. This document audit is very time-consuming and labor intensive – a person in charge should have extensive knowledge in both law and medicine. Since the flow of the documents is never-ending and comes in like a tide, the insurance companies often choose to outsource their audit work to other companies who specialize in it. One of these insurance audit companies approached us to develop a system that would make big volumes of audit documents structured and the process itself run like clockwork.

Automated workflows

Every insured case coming into the system is included into its own “item” – a separate entity that encompasses everything there is to know about the case: documentation, links to the insured person, to their employee, to the hospital they stayed in, the treatment plan, drugs the doctor prescribed, etc. Two operators cannot work on the same item simultaneously: one operator does their part of the job, leaves comments or notes and then passes the item to another operator. This approach insures accurate and scrupulous auditing process that leaves no place for mistakes. If a mistake somehow happens, it is easily trackable to a person and a timestamp, and a person in charge can quickly address it and fix.

We automated dozens of different workflows that determined the item path depending on many factors: current status, current operator, information completeness and many more to determine to what operator it should go next. Operators, in turn, have a set of permissions that let them access a number of item queues. These workflows cover all possible audit scenarios: whatever case comes in, it falls into one of the workflows perfectly and the processing goes smoothly.

Every change to the item is logged to easily see who changed what and from what queue. The system is tailored in such a way that every operator only has access to the information they absolutely need to make a decision on their level of competence. Somebody would need the info on the employee, someone else – on the prescribed drugs, and usually these two operators do not cross paths. Item history and change logs are essential to safe and secure audit: it allows managers to supervise the process and immediately see and address any suspicious cases, allowing for maximum control and accuracy.

Confidentiality and sensitive data management

Since this system manages a lot of personal information and other sensitive data, we implemented an elaborate hierarchical access right system to make sure that every employee has access only to the information they need and nothing else. The system falls into several units and each unit is a subsystem responsible for one particular thing: drug prescriptions, surgeries, etc. The employee has to have separate credentials for the system as a whole and for each unit they are permitted to access, if more than one. Moreover, each failed attempt to log into a unit that the employee is not supposed to access is caught by the system and documented. Security comes first.

Even inside each unit operators have different access rights, no more than absolutely necessary. For example, Josh is investigating Samantha’s case inside a drug prescription unit. He cannot look up information on any other case that this unit contains until he is appointed its operator.

Analytics

The system allows employees to generate hundreds of analytical reports with the information they have access to. They can get reports on a particular case, stats on the process of working on several items or just analytical reports on other employees. Reports cover pretty much everything a manager or an administrator might want statistics on to determine effectiveness and have a snapshot of the company productivity at any given time.

Development process and challenges

When we started working with our client, we were supposed to develop a simple import tool and not a giant multi-unit system for processing documents and sensitive data. The project was changing over the years and some features were naturally going out of date, and being replaced with more modern and effective approaches. We were not the only team working on this project, there were three more groups of developers, and sometimes during the development process, collisions happened, but nothing good communication could not resolve. The fact that our client operated a lot of sensitive data, also was quite a challenge in the development and testing process but we always found a way to implement, test or fix while following all the rules and abiding by law.

Results

We completed this project 2 years ago and continuously supported it while our clients needed our assistance. This project gave us a lot of experience not only in development but also in communication. It might appear too difficult to work on the same project with several other teams but this was a moment for our communication skills to shine. In development, there are no managerial issues that cannot be resolved by a fine-tuned communication between all participants. This giant audit system should be a reminder for one simple truth – in our day and time, there are no processes too big or too complicated to automate and make more effective.

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