Legacy Systems Software Transition
Client: DHHS, Centers for Medicare and Medicaid Services (CMS)
Issue:
- The Centers for Medicare and Medicaid (CMS) awarded PBSI the contract for developing, maintaining, and enhancing the Fiscal Intermediary Shared System (FISS), the national Medicare Part A software system used for processing over 85 million hospital claims annually.
- Serious attrition problems were occurring with the staff of the previous maintainer.
Methodology:
- Key staff were identified during planning process and immediately assigned to manage the FISS team.
- Special workgroups were established, including staff from the incumbent to facilitate communication.
- Detailed plans were created in the areas of security, disaster recovery, quality assurance, configuration, risk management, and release management.
- Each change was tested various phases: unit, regression, volume, and user acceptance, and tools were implemented to track test cases, ensuring awareness of any issues with the release.
- Process was established to ensure the system went through regression test on monthly basis.
Outcome:
CMS received earlier implementation than originally planned, resulting in reduced transition costs with minimal or no disruption to beneficiary and provider services.
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Case Study: Common Edit Module (CEM) Development
Client: DHHS, Centers for Medicare and Medicaid Services (CMS)
Issue:
- CMS allowed their multiple Medicare Administrative Contractors (MACs) that process Medicare claims to accept claims in ANSI X12 format and choose which COTS ANSI translator they would like to use.
- CMS has specific data requirements that need to be verified and reported back to the submitter before the file is passed on to be paid, which requires coding approximately 400 CMS edits into each of the chosen translators.
- CMS tasked PBSI to create a new Common Edit Module (CEM) to verify the translator output before passing the file on for payment.
Methodology:
- The PBSI innovative solution blended Java programming, XML, and the ISO-standard open source Schematron rule-based validation engine into a streamlined workflow which perform the needed validation.
Outcome:
The new CEM improved efficiency and reliability by:
- Removing need for multiple database tables to represent the data structure;
- Enabling complex, multi-record edits;
- Allowing any XML file to be used for validate values;
- Coding all edits as "Schematron Rules" instead of coding them in Java or other proprietary edit environment;
- Filtering claims with "errors";
- Passing clean claims on for processing;
- Providing immediate feedback on claim status to the submitter;
- Allowing file balancing between the provider, translator, and payment system.
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Case Study: Operations Workload Transition
Client: DHHS, Centers for Medicare and Medicaid Services (CMS)
Issue:
TriSpan Health Services, the Medicare fiscal intermediary (hospital claim processor) for Mississippi and Louisiana, terminated their Medicare contract with CMS effective September 30, 2009. On July 28, 2009, PBSI was requested by the Blue Cross Blue Shield Association and DHHS/CMS to transition the legacy Mississippi Part A and Louisiana Part A workload to PBSI operations. The timeline for the aggressive transition of this workload was 9 weeks with a cutover date of September 30, 2009. Medicare payments to providers and beneficiaries were at risk if these timeframes were not met.
Methodology:
Six Transition Workgroup leads were named, and a meeting calendar was developed which provided structure for our internal and external transition discussions and ensured that all stakeholders were allowed a current status and a forum for communicating transition issues and activities. PBSI implemented CMS requirements, including reporting, CMS oversight, and plan development. Rigorous testing with all relevant IT systems was conducted to ensure the seamless processing and payment of Medicare claims continues.
Outcome:
PBSI successfully transitioned the TriSpan Legacy workload, effective October 1, 2009. CMS presented a Certificate of Appreciation to PBSI at the National CMS Medicare Executive Contractor’s Meeting, in recognition of our highly successful transition in an unprecedented two month timeframe.
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Case Study: Operations Workload Transition: CICS Merge
Client: DHHS, Centers for Medicare and Medicaid Services (CMS)
Issue
- Medicare Part A (hospital claims) workloads for Arkansas, Louisiana, and Mississippi were processing in four individual Customer Information Control System (CICS) regions: two production and two user acceptance testing.
- In order to maximize efficiency and cost savings, CMS requested that PBSI merge the four regions into two.
Methodology:
- Facilitated all associated user workgroups for the support of this merge process and developed Medical Policies, edits and, audits for a single processing workload.
- Close coordination with all stakeholders including Enterprise Data Centers, system maintainers, specialty contractors and CMS to ensure all were aware of project status and discuss timely issue resolution.
Outcome:
The CICS merge went into production August 2, 2010, one month earlier.
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