RPA, AI help speed review of Medicare claims

The Centers for Medicare and Medicaid Services is using the Intake Process Automation Tool to validate information on Medicare Advantage claims and identify potential problems for staff reviewers.

Employees and contractors at the Centers of Medicare and Medicaid Services spend countless hours every year reviewing thousands of medical records to ensure the accuracy of Medicare Advantage payments. An automated intake tool is working to change that.

Using emerging technologies such as robotic process automation, optical character recognition, machine learning and artificial intelligence, KPMG’s Intake Process Automation Tool ingests records as they are submitted and identifies potential problems according to set parameters, submission rules and coding guidance. Specifically, RPA orchestrates the steps of the intake process, OCR digitizes the scanned document and then AI and machine learning are applied to understand the document and extract the information necessary to validate the information.

Intake PA stands to save CMS time and money, said Payam Mousavi, KPMG’s lead director for intelligent automation for governments and the technical lead for the CMS project. The tool processes a record in about a minute, whereas human reviewers average about 65 minutes per record.  The agency received 40,000 records in 2018 and expects to get 50,000 this year.

To submit records, health care providers scan them in, resulting in varying formats and lengths. “It could go anywhere a few pages to over 1,000 pages,” Mousavi said. “Because they’re scanned in, there’s sometimes handwriting in them.”

In the past, the CMS staff reviewed  all that unstructured data, making  sure the scans of records were rotated properly and going page by page to check that they had the right date of service, provider and beneficiary.

Now, OCR handles the digitization, but to make sure that names, birthdates and other identifiers within one record match, KPMG created microservices that use natural language processing and machine learning to distinguish between a date of birth and a date of service. Once that data is in a structured format, it’s possible to do the validations automatically for each page, Mousavi said.

“If you look at a medical record, you may have multiple names in there,” he said. “You may have the patient name, you may have the physician name, you may have a nurse name, you may have a street name. To a human, it’s pretty easy to differentiate between them, but if you have a machine looking at it, that’s where we’re using natural language processing and machine learning to understand the document like a person would.”

Much of the tool is new technology that CMS did not have, Mousavi said. His team saw the highly manual, repetitive process as a good use case for RPA, but RPA is not ideal for unstructured data or making decisions, he added. That’s where AI and the KPMG Ignite AI platform come in. It has natural language processing and machine learning algorithms to help understand the unstructured data in the documents.

Besides time savings, Mousavi sees two other benefits to the tool. The first is cost savings because CMS doesn’t have to pay employees or contractors to handle the repetitive tasks and PA Intake can run 24/7. Still, the tool doesn’t completely remove humans from the review process. If the tool doesn’t have high confidence in the decision it made, the record will go to a person for verification.

“There are still some steps that cannot be automated or haven’t been automated yet or regulations don’t allow them to be automated,” Mousavi said. “But the expectation is that they’re going to get done faster.” And that translates to faster feedback to providers and better job satisfaction because workers are looking only at complicated records, not checking all the information on every single one.

Another perk is increased accuracy. In fact, the tool returns 95 percent accuracy, and a test found cases in which the bot discovered something invalid that a human had overlooked. “If you’re looking at 1,000 pages, it’s easy as a human to miss some of these things,” Mousavi said.

Since the PA Intake went live in April, it has processed more than 6,000 records. Currently, CMS is using one tool, but it hopes to have multiple bots up and running to speed the process further. In the fall, KPMG expects to add more validations such as whether the forms have signatures.

In May, the tool earned KPMG a spot as one of eight finalists at ACT-IAC’s Igniting Innovation 2019 conference, an event highlights the newest technologies in the public sector.

Editor's note: This article was changed July 2 to correct the spelling of Payam Mousavi's name.

NEXT STORY: How CX drives modernization

X
This website uses cookies to enhance user experience and to analyze performance and traffic on our website. We also share information about your use of our site with our social media, advertising and analytics partners. Learn More / Do Not Sell My Personal Information
Accept Cookies
X
Cookie Preferences Cookie List

Do Not Sell My Personal Information

When you visit our website, we store cookies on your browser to collect information. The information collected might relate to you, your preferences or your device, and is mostly used to make the site work as you expect it to and to provide a more personalized web experience. However, you can choose not to allow certain types of cookies, which may impact your experience of the site and the services we are able to offer. Click on the different category headings to find out more and change our default settings according to your preference. You cannot opt-out of our First Party Strictly Necessary Cookies as they are deployed in order to ensure the proper functioning of our website (such as prompting the cookie banner and remembering your settings, to log into your account, to redirect you when you log out, etc.). For more information about the First and Third Party Cookies used please follow this link.

Allow All Cookies

Manage Consent Preferences

Strictly Necessary Cookies - Always Active

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Sale of Personal Data, Targeting & Social Media Cookies

Under the California Consumer Privacy Act, you have the right to opt-out of the sale of your personal information to third parties. These cookies collect information for analytics and to personalize your experience with targeted ads. You may exercise your right to opt out of the sale of personal information by using this toggle switch. If you opt out we will not be able to offer you personalised ads and will not hand over your personal information to any third parties. Additionally, you may contact our legal department for further clarification about your rights as a California consumer by using this Exercise My Rights link

If you have enabled privacy controls on your browser (such as a plugin), we have to take that as a valid request to opt-out. Therefore we would not be able to track your activity through the web. This may affect our ability to personalize ads according to your preferences.

Targeting cookies may be set through our site by our advertising partners. They may be used by those companies to build a profile of your interests and show you relevant adverts on other sites. They do not store directly personal information, but are based on uniquely identifying your browser and internet device. If you do not allow these cookies, you will experience less targeted advertising.

Social media cookies are set by a range of social media services that we have added to the site to enable you to share our content with your friends and networks. They are capable of tracking your browser across other sites and building up a profile of your interests. This may impact the content and messages you see on other websites you visit. If you do not allow these cookies you may not be able to use or see these sharing tools.

If you want to opt out of all of our lead reports and lists, please submit a privacy request at our Do Not Sell page.

Save Settings
Cookie Preferences Cookie List

Cookie List

A cookie is a small piece of data (text file) that a website – when visited by a user – asks your browser to store on your device in order to remember information about you, such as your language preference or login information. Those cookies are set by us and called first-party cookies. We also use third-party cookies – which are cookies from a domain different than the domain of the website you are visiting – for our advertising and marketing efforts. More specifically, we use cookies and other tracking technologies for the following purposes:

Strictly Necessary Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Functional Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Performance Cookies

We do not allow you to opt-out of our certain cookies, as they are necessary to ensure the proper functioning of our website (such as prompting our cookie banner and remembering your privacy choices) and/or to monitor site performance. These cookies are not used in a way that constitutes a “sale” of your data under the CCPA. You can set your browser to block or alert you about these cookies, but some parts of the site will not work as intended if you do so. You can usually find these settings in the Options or Preferences menu of your browser. Visit www.allaboutcookies.org to learn more.

Sale of Personal Data

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.

Social Media Cookies

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.

Targeting Cookies

We also use cookies to personalize your experience on our websites, including by determining the most relevant content and advertisements to show you, and to monitor site traffic and performance, so that we may improve our websites and your experience. You may opt out of our use of such cookies (and the associated “sale” of your Personal Information) by using this toggle switch. You will still see some advertising, regardless of your selection. Because we do not track you across different devices, browsers and GEMG properties, your selection will take effect only on this browser, this device and this website.