Dr. Brian: OK so let's start with Automated Reporting. What is that?

Automated Reporting

Erez: We need to track the quality of five key roles of the overall team on a continual basis and the reports need to come to us automatically. This is the opposite of manually spot checking and tallying up numbers to grade the performance of each one of these roles in the billing team.

1. Individual auditor performance - claims audited, errors found, and audit quality (errors found in auditor's samples)
2. Operator performance
3. BPO performance
4. SPOC performance
5. Overall quality - SPOC Manager

Dr. Brian: So now I understand who need to be audited and that there will be reports automatically generated to help you see the quality, but what is really being measured and, how can you trust that auditors are not making mistakes?

Multiple Audit Levels

Erez: To make sure that the auditors do their job properly, we need to do two things:

1. Measure audit progress
2. Audit the auditors

We envision four levels of independent auditors: 1st level auditor, 2nd level auditor, SPOC, and SPOC manager. The technology samples the claims for the audit automatically and allocates them in the corresponding audit workbench. For instance, the technology selects the claims for second-level audits by a random probability defined in the audit-risk database from the claim sample already selected for the first-level audit. Second-level auditors would in turn be audited automatically by the SPOCs, and the SPOCs would themselves be audited by the SPOC Manager.

The claim sample selected for a second-level audit increases whenever the independent QA team finds mistakes or oversight on the part of the first-level auditing teams. In this way, a single claim may be audited by up to four independent auditors. If one of the auditors finds a mistake, the entire chain of auditors and the processor who made the initial mistake will all have their "audit-risk" increased so that more of their claims are audited.

Dr. Brian: So Kind of like an immune response? The more mistakes the bigger the defense?

Erez: Something like that.

Dr. Brian: I understand how there are different levels of auditors but they still need to go and randomly select claims right? How can you be sure that they are selecting random claims and not ones that look like they will be easy to audit?

Workflow Management

Erez: As in standard billing processing, with automated problem discovery and manual resolution, the technology automatically selects the claims for audit and populates the audit workbenches with those claims to ensure audit task completion. Auditors get a list of claims with the notes entered by the processing teams, and then:

1. Audit the claim completely (including calling the insurance company or checking status online to make sure the information obtained by the operator is correct)
2. Record errors or mark the claim as clean

By working from a workbench, the audit teams will be able to do their job faster. More importantly, the technology will automatically measure the auditors' progress and productivity to make sure that all sampled claims are getting audited.

Dr. Brian: The system tells the auditors what and when to audit and also measures how clean the claims are?

Erez: Yes

Dr. Brian: What exactly is fair game for auditing?

Automated Audit Sampling

Erez: The operator actions subject to audit include EOB posting, a follow-up action, or a request for info to the provider. Every action performed by an operator is automatically compared to a "audit-risk" database that determines the chances that the action will be audited. The "audit-risk" is configured in the technology by entering a percentage chance of auditing an action, for an individual operator, an auditor, or an entire team.

For example, if we bring on a new follow-up team, we may configure their "audit-risk" at 100%, ensure that every action they perform on every claim will be audited. As the team proves themselves, we can reduce this "audit-risk" to 50% and later to 20%, as long as the auditors find few errors in their audits.



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