Case Study: QAT Flow Workflow to Automate Medicare/Medicaid Retroactive Processing Audits

A regional auditor for the Centers for Midicare & Medicaid Services division of the Federal Government Health & Human Services department is a new adopter of QAT Flow. They are responsible for the retroactive processing of Medicare and Medicaid claims.  Currently, this is a labor intensive, manual auditing and data entry process.  QAT Flow has been chosen as a solution to automate and streamline the process from start to finish.

QAT Flow will provide some major benefits:

• Every step of the process will be controlled or guided by the Workflows.  Managers and customer services reps will know the exact status of any claim as it works its way through the audit process.
  
• User manuals and extensive training will be “a thing of the past”.  Each step will have detailed instructions embedded in the Workflow.  These instructions are dynamic and can be modified as required by the Business User Administrators.  No IT support will be required for these updates.
  
• Data entry and auditing personnel will only be present the steps necessary based on the type of claim they are processing.  The business logic to determine the sequence of steps will be embedded in the Workflow and can be dynamically changed as required by the Business User Administrators.   No IT support will be required for these updates.
  
• The manual process of validating data values against hard copy sources will be automated using parameter validation rules.  When a parameter value is outside of the defined rule, the value will be flagged or the workflow will dynamically take the user through a custom work path to resolve the issue.  The validation rules will be defined in the Workflow by the Business User Administrators and can be modified as required.  No IT support will be required to define or modify these rules.
  
• Plug-ins will be registered and embedded in the Workflow to add/update/delete data in the enterprise repository.  The timing and sequencing of these data base operations will be controlled by the workflow logic as designed by the Business User Administrators.  Once the plug-ins are created, no additional IT support will be required.
  
• By using the extensive versions control features of QAT Flow, a permanent history of the Workflows and the rules included at the time a claim is processed will always be available.  This will simplify the review process when the results of an audit are challenged.
  
• Internal audits of the auditing process will also be controlled by Workflows to insure a consistent QA approach for monitoring the process.
  
• QAT Flow will provide invaluable process data to the business managers.  A complete history trail is available for every item processed.  This data can be queried to identify bottlenecks in the process and establish benchmarks for processing performance that can be used to evaluate the performance of individual employees.
  

In addition to the immediate benefits provided by a robust workflow solution, QAT Flow will be tightly integrated with a full featured document imaging and management solution.  As the audit process proceeds, documents will be seamlessly retrieved from the document management system and presented to the auditors as required.  The timing of the retrievals will be controlled by the Workflow logic as defined by the Business User Administrators.

For more information, please visit QAT Flow.