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Claims (Healthcare Claims)

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Challenge

The Department of Veteran Affairs (VA) manages the authorization, claims processing, and reimbursement for services acquired from Non-VA Healthcare providers through the Chief Business Office Purchased Care (CBOPC) Business Line. The VA had a need to support the CBOPC with a Centralized Services solution and support the division as the single authority responsible for the distribution of payments to community providers for their delivery of health care to Veterans and Veterans’ Family Members, of which they process over 13 million claims annually amounting to billions of dollars in annual payments.

Solution

ASG addressed the VA’s challenge by building a Centralized Rules Services (CJS) interface, which enables the business staff with an interface the processing of claims that resulted in improved payment accuracy and operational timeliness without requiring Office of Information Technology (OIT) developer resources, OIT funding, or the involvement of the OIT prioritization process. The rules solution is useable for both existing claims processing models and in-development of a future-state model.

The ASG team conducted analysis of payer logic for the claims management system in which we examined existing rules, and to extract, examine, analyze logic, compare to requirements, propose and make changes, adapt/modify software, and rollout for deployment. Using the IBM Websphere ILOG business rules management application software, the ASG team managed the full lifecycle of healthcare claims adjudication processes, as well as related code sets. ASG developed, tested, and managed the business rules requirements on an ongoing basis as legislation and program integrity changes were released.

For the Rules project ASG has met the VA’s ultimate goal, which is to enable CBOPC government staff, especially from Program Integrity, Policy Management, Insurance Review and Resolution, Informatics, Health Care / Clinical Review, Business Systems Management, to use centralized technical and management resources to support all directorates in the use of automated business rules management systems to support fraud, waste and abuse detection, automate claims processing, and enable policy adjudication without human intervention.

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