NASA Scientific and Technical Aerospace Reports

Managed care organizations (MCO) must make every effort to improve the effectiveness of claims processing and
reporting or they will risk the loss of member and provider satisfaction and ultimately lose their ability to remain solvent. The
status of claims administration has been elevated in light of the fact that somewhere between 73 and 93 percent of all premium
dollars are paid out for medical care in capitation and claims payments. An effective MCO will use claims processing data
to manage the cost of health care on a case basis and in aggregate. Designing appropriate claims reports is essential to a
well-managed healthcare organization s ability to effectively forecast liability trends and institute corrective steps. When
TRICARE Managed Care Support Contracts were brought on-line there was no longer a direct contractual relationship
between the FI and the government. Consequently, the Departmentof Defense was no longer at risk for either the expenditure
of healthcare dollars or the adjudication of claims. Unfortunately, TMA continued to monitor the MCSC as if the government
maintained the risk and was overly prescriptive with literally thousands of edits that slowed the claim process down.
TRICARE has had claims processing timeliness and accuracy issues since its inception due in large part to the numerous
eligibility categories, differing cost shares and benefits, the three health plan options (Prime, Extra, and Standard), and its
reliance on data exchanges. TRICARE Management Activity (TMA) recognized that failure to respond immediately to
beneficiary and provider concerns regarding claims processing would result in the loss of both patients and network providers.
TMA tightened the timeliness standard of 75 percent of claims processed within 21 days to 95 percent of clean claims within
30 days and 100 percent in 60 days. This case study was conducte
DTIC
Claiming; Health; Management Planning; Simplification
20040050699 Academy of Health Sciences (Army), Fort Sam Houston, TX
An Evaluation of the Costs and Benefits Associated with Purchasing an Anesthesia Automated Record Keeper at
Wilford Hall Medical Center
Buckner, Jason E.; Mar. 30, 2001; 59 pp.; In English; Original contains color illustrations
Report No.(s): AD-A420983; HCA-33-01; No Copyright; Avail: CASI; A04, Hardcopy
In October, 2000, under the guidance of Colonel Jay Ellis, Chief Consultant for Anesthesiology to the Air Force Surgeon
General, the researcher began to evaluate the costs and benefits associated with purchasing anesthesia automated record
keepers (AARKs) for Wilford Hall Medical Center in San Antonio, Texas. Wilford Hall’s anesthesia department was devoid
of any meaningful information management system, making theft and waste possible, and making research and drug
management nearly impossible. Preliminary investigation showed that the Department of Defense (DoD) had evaluated
potential AARKs and had chosen to endorse the Anesthesia Information Management System (AIMS) by LifeCare
Technologies, thus the focus of the study was a cost-benefit analysis of AIMS, to determine whether or not the benefits would
justify the exorbitant costs of its purchase and continued utilization. The literature indicated that savings could be realized in
the form of reduced costs of anesthetics, practice improvements through outcomes research, and fewer medicolegal losses.
Obstacles include staff resistance and systems support and compatibility, the latter of which caused AIMS to fail at the original
DoD test site, Brooke Army Medical Center. Since the DoD pays military medicolegal losses, this benefit would be realized
only from the perspective of the DoD; WHMC s budget would not change. This led to evaluation from both of these
perspectives. Each cost and each benefit required its own form of investigation, most notably the benefit of increased third
party collections. Several of these were found to hold uncertain values, thus scenario and sensitivity analyses were performed
on the five most critical elements. The results of best estimates were as follows: From the WHMC perspective, the 10-year
net present value (NPV)= - $82,633, with a payback period of 8.210 years; from the DoD
DTIC
Anesthesia; Costs; Health; Management Planning
20040050703 Academy of Health Sciences (Army), Fort Sam Houston, TX
Referral Process Improvement: A Study of the Efficiency and Tracking Processes for In-house Referrals at Blanchfield
Army Community Hospital
Hoiden, Timothy J.; Apr. 2, 2002; 58 pp.; In English
Report No.(s): AD-A420987; HCA-12-02; No Copyright; Avail: CASI; A04, Hardcopy
The purpose of this study was to evaluate the referral process from primary care managers (PCMs) to specialists at
Blanchfield Army Community Hospital (BACH). Specifically, the study revealed key elements of an ideal referral process
from the literature review and compared those elements with the referral process at BACH. Indicators were then developed
to determine the efficiency of BACH s referral process. Statistical significance was found to exist in both the developed
benchmarks (n = 1885) of each indicator at the 95% confidence interval. Finally, recommendations for improving the referral
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