A Healthy Operation

VA 'scrubs' claims data to keep billing system in the pink.

When faced with the need to more efficiently send bills to insurance providers, the Department of Veterans Affairs felt comfortable using commercial off-the-shelf data scrubbing software.

But when it came time to integrate that software with the agencys legacy billing software, officials called in Daou Systems Inc. for help. The professional services company provides IT design, deployment, integration and support for the health care industry, and it also knows the governments legacy systems—a key factor in integrating often mammoth systems with newer off-the-shelf applications.

Carey Dolan, director of business development with Daous Government and Integration Services division, said his company works with several agencies. "The common denominator is those [agencies] systems are all hospital information systems that were developed using [the] MUMPS [programming language]," Dolan said. "Thats our core competency—understanding those core systems."

Barbara Mayerick, deputy director of business development, chief business office at the VA, explained that the department seeks third-party reimbursements for veterans non-services-connected care. That results in the VA sending about 10 million claims each year to insurance companies.

Mayerick needed a way to augment the Washington-based agencys VISTA (Veterans Integrated System Technology Architecture) billing system with an application that would "scrub" claims data for errors before it was released to insurance agencies.

"We wanted to increase our sophistication in submitting claims to ensure that edits submitted by payers were addressed," said Mayerick. "We had a mandate to include [the scrubbing] software in the field, and we needed an integrator to enable nationwide use."

The VA had already decided on a commercial claims scrubbing software package—which Mayerick chose not to identify—and the VA looked to Daou to write the interfaces.

Daou, of Kensington, Md., wrote the interface between the claims scrubbing application, which resides on a dedicated server, and the VISTA system where claims are analyzed via a bidirectional, real-time TCP/IP interface. With that analysis, VISTA is able to edit the knowledge-base entries and rules that are used to analyze the claims and have them corrected through the VISTA screens.

At the same time, safety procedures were put in place to capture billing data that is not transmitted to the scrubbing application because of communication problems, according to Daou. Those bills have the ability to be requeued for transmission once problems are resolved and the system becomes available.

VISTA messages were also created to notify the person who initiated a bill the status of its transmission, and capabilities were put in place so users can send single or bulk billing transmission failures to the scrubbing software.

"While the VISTA biller is on their screen and they have this bill, we transmit [information in] real time and bidirectionally, so there is a stream of data going from VISTA to the claims scrubber [and back]. All this takes about a second," said Eric Gustafson, senior consultant at Daou. "Response time and performance is critical for this. [The VA] specifically wanted this to be done on a claim-by-claim, real-time interface. We took the challenge and produced a very fast system."

It was no small job. Organized into 21 networks with 1,300 care facilities, 162 hospitals, 850 outpatient clinics and 137 nursing homes, the VA is the largest centrally run health care provider in the country. It also has one health administration system. VISTA is an automated environment that supports day-to-day operations at local VA health care facilities and incorporates all information resources vital to the operations of those facilities.

The ultimate goal for Daou was to increase revenue for the VA by decreasing claims exceptions, Gustafson said. For the VAs Mayerick, the goal in choosing Daou to do the interface work went a bit deeper.

"I dont think the software provider had the expertise or specialized knowledge to bridge the gap between themselves and the VA," said Mayerick. "The use of an integrator made sense from a resource allocation perspective, and to make use of their specialized expertise. They also coordinated the effort and made good use of our project timeline."