Knowledge Objects AHIA Claims Leakage & Fraud Forum August 2007 Rodney Boyd Managing Director Knowledge Objects Healthcare Australia Pty Ltd Level 2, 10 -14 Bulletin Place Sydney NSW 2000 Australia Telephone (02) 8213 3579 www. Knowledge. Objects. com. au
Today’s Agenda About our company Claims leakage: common problems About our services & software Common findings 24 months… key learnings A vision of the future Copyright 2006 Knowledge Objects Healthcare Australia Pty Ltd 2
About Knowledge Objects Established in 1996 15 health funds – Asia, Africa, Australia In Australia for two years Mission = help PHI funds stop claims leakage Part of the Bathabile Group 3
About Bathabile Technology & health insurance risk management 14 companies 5 countries, 4 continents Clients = health insurers, managed care organisations, government departments 4
Common Failings… Worldwide IT systems built for transaction processing Rules are hard coded Limited specialist focus on leakage The business can’t manage the process The fund can’t afford specialist clinical expertise 5
About Knowledge. Power™ Proprietary developed claim rules engine Supplement existing technology Increase automation Stop the claim before payment - be proactive, not retrospective Let the business define & manage the rules without IT involvement 6
About Knowledge. Power™ (continued) Provide a “process” and tools required to implement a rules based claims leakage programme Store “knowledge” in a central repository Measure and report 7
Knowledge. Power Rule Types Claim Padding / Card Farming Limit Surfing / Provider Collusion Smart Duplicates / Over Servicing Erroneous hospital claims Provider / Member / User alerts & tracking Plus… product rules, membership rules, customer retention etc… if you have the data then Knowledge. Power can build the rule 8
How to use Knowledge. Power Health fund philosophy to claims leakage established Data mining & retrospective analysis Knowledge. Power 1. Write rule 2. Test within Knowledge. Power 3. Adjust rule 4. Generate within Test environment 5. Test rule 6. Fund sign-off 7. Generate within Production environment Investigate and action 9
How Knowledge. Power Works Claims • Branch Claims Assessing Process Administration System • Paper • Hicaps • EDI • Manual Capture • Web interface Business Process One Business Process Two Business Process Three Reject Payment • Eclipse • Thelma 10
How Knowledge. Power Works Knowledge. Power. TM Automated Code Generation Claims • Branch Claims Assessing Process Administration System Knowledge. Power Machine Code • Paper • Hicaps • EDI • Manual Capture • Web interface Business Process One Business Process Two Reject Calling Program Business Process Three Payment • Eclipse • Thelma KP: Reject / Refer / Tag Reject 11
How Knowledge. Power Works Knowledge Objects Health Fund Rule Managers Fraud Ancillary Hospital Knowledge Objects Rule Engineer Medical Knowledge. Power. TM Automated Code Generation Claims • Branch Claims Assessing Process Administration System Knowledge. Power Machine Code • Paper • Hicaps • EDI • Manual Capture • Web interface Business Process One Business Process Two Reject Calling Program Business Process Three Payment • Eclipse • Thelma KP: Reject / Refer / Tag Reject 12
How Knowledge. Power Works Knowledge Objects Health Fund Rule Managers Fraud Ancillary Hospital Knowledge Objects Rule Engineer Medical Knowledge. Power. TM Claims. Express Automated Code Generation Claims • Branch Claims Assessing Process Administration System Fund Claims Adjudicator Knowledge. Power Machine Code Claims scored: Reject / Pay / Investigate • Paper • Hicaps • EDI • Manual Capture • Web interface Business Process One Business Process Two Reject Calling Program Business Process Three Payment • Eclipse • Thelma Recover KP: Reject / Refer / Tag Reject 13
How Knowledge. Power Works 14
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How Knowledge. Power Works A B C 17
How Knowledge. Power Works C B A 18
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How Knowledge. Power Works A B C 20
Common Firings Mismatches between hospital & medical claims Prothesis & materials not accompanied by procedures Dental rules relating to age restrictions Dental rules not following ADA guidelines Excessive ancillary claiming patterns Conflicting MBS charges Excessive LOS for procedures 21
After 24 Months… Key Learnings Rule management requires commitment The philosophy of leakage management requires top management buy in, it’s an EXCO level discussion as it requires trade offs A natural tension exists between leakage minimisation and other divisions of the fund eg claims assessing, provider relations. A balance is required which requires high level management intervention 22
After 24 Months… Key Learnings The process of managing rules is as important as the rules themselves Resources are always limited so focus is imperative Set a strategy for rule development and follow it Intellect beats man power – but both are better 30 more minutes of structured testing can save days of wasted effort 23
After 24 Months… Key Learnings Lack of data = disempowerment Consistency in claims assessing processes is vital for rules to work Reporting and definitions are crucial 24
A Vision A greater focus on claims leakage in the board rooms of PHI funds in Australia A greater willingness to accept that as key funder of healthcare in Aus the PHI industry has a right and responsibility to manage claims leakage for the benefit of all members Increased collaboration: a common industry set of rules, augmented by individual fund rule sets More clinical based rules to monitor appropriateness of care A common panel of industry accepted clinical experts Every fund using Knowledge. Power! 25
Thank You! 26
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