3. • Medicare claims for 4 states in the
southwest.
• Approximately 80 employees
• Subsidiary of Acme Corporation
– One of the largest affiliations of health-care
plans in the southwest
4.
5.
6. Consequence Solution
• Lost/stolen/mishandled • Convert paper claims into
paper claims electronic format using
Optical Character
Recognition (OCR)
7. Consequence Solution
• Unintentional authorization • Acme and MSW becoming
and denial of access to data separate
entry facilities entities, eliminating overlap
in terms of employee and
facilities
8.
9. Consequence Solution
• Compromise of system • Creation and maintenance
integrity of computer systems by
third, unaffiliated party
10. Consequence Solution
• Malicious Acme employee • Error-specific messages in
continually altering claims electronic screening
until desired result passes • Allow changes only to
electronic screening erroneous sections of the
claim
11.
12. Consequence Solution
• Lack of incentive/motivation • Utilize full-time workers
• Possible improper treatment
of company data
• Inability to hire desirable
workers
• Inability to fire undesirable
workers
13. Consequence Solution
• Unnecessary loss of funds • Audit current screening
system
– Access to patients’ medical
history.
– Inbuilt checks against
conflicting procedures
14. Consequence Solution
• Processing of erroneous • Two screening systems
claims
15. Consequence Solution
• Loss of data • Backup database system
• Inability to process claims – Data synchronization
– Separate power supply
16.
17. Consequence Solution
• Acme workers assisting in • Acme and MSW becoming
MSW’s daily operations separate entities,
– Violates legal obligation eliminating overlap in terms
of employee and facilities
18. Consequence Solution
• Compromise of system • Creation and maintenance
integrity of systems by
third, unaffiliated party
• Acme and MSW becoming
separate
entities, eliminating overlap
in terms of employee and
facilities
19. • System efficiency test
• Financial statement analysis
• Benchmarking
• Facility breach test
• Erroneous data entry test
20.
21. • Cost
• Turnover time
• Customer support options
• Experience
Editor's Notes
MSW receives two types of claims: electronic and paper copies. After paper claims are received, they are sorted in the mailroom. Also sorted in the mailroom are the claims of all other subsidiaries. After sorted, it is then delivered to an Acme employee to be entered into the system. Between the claims being received, sorted, and sent off, there is a high potential for these paper claims being lost, mishandled, or stolen. Utilizing optical character recognition (OCR), paper claims will be converted into electronic claims. They will then follow the exact same procedures as the electronic claims. This not only reduces the cost incurred by the paper claim processing system, but also allows uniformity of their overall claims system. This also increases the efficiency of the process since it takes less time, and capital, to scan a claim into the system than sorting and manually entering it.
MSW shares their mailroom, data entry area, as well as their overall facility with all the other subsidiaries. Because of this there is the risk of unintentional authorization of access to data entry facility for recently fired employees as well as the risk of unintentional denial of access to data entry facility for recently hired employees.To mitigate this risk we believe that Acme and MSW have to act as separate entities. Acme should not be providing MSW with employees. Rather, MSW should be directly hiring their own employees. Also, MSW has an unsafe level of overlap with other Acme subsidiaries in their facility.
Transition to Electronic
J
K
G
D
Another risk that identified with MSW’s claims processing system is the fact that once the electronic claims are screened and are deemed to be error-free, a check is automatically created and mailed to the health care provider. The system can never be assumed to be functioning at 100% correctness, but under current conditions if something is wrong with a claim that the system does not pick up, the check is still automatically mailed out to the health care provider. The electronic screening system will be supplemented with an additional electronic screening system. If either of the systems fails, an alternate routing path will be followed for the claims to ensure that the systems are mutually exclusive. This will lower the possibility of erroneous claims being deemed error free and sent out.
MSW only has 1 database. If something was to happen to MSW’s database server all of their data could be erased or damaged. More immediately, the system will be down and unresponsive, leaving MSW without the ability to process any claims. This not only costs MSW time and money, but will also hurt the company’s image and reputation. To mitigate this risk we would be implementing a backup database system for MSW. The second database system will have data synchronization with the first. Given a situation of one system malfunctioning, the second system will contain all the data the malfunctioning data system has and will allow the company to continue with operations. The second system will also be hooked up to a backup generator in case of power failure.
F
A Risk- Talk on violating legal obligation to remain as separate entities Conflict of Interest
E & I(In terms of data enterers for databaseAND lead programmers for claims payment system)
System efficiency testTurnover time? Errors found and amended? (spped+accuracy) Financial statement analysisReview financials during the year and at the end of the year, checking for amount lost on fraudulent claims, duplicate payments, and erroneous claims. Check if improvements put in place have lowered the amount lost and corrected any previous mistakes made by MSW. Benchmarking Compare against other firms turnover time, fraud claims, dup paymnets, etcFacility breach test
