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GCN Home > 10/09/06 issue

Military systems in the pink

GCN Agency Award | Claims processing system for military health care streamlines payments, encouraging participation

By Edmund X. DeJesus, Special to GCN

When you’re sick, you go to the doctor. When you get hurt, you visit the emergency room. But when your medical plan is on the gurney? Systems engineers and planners can help.

The TRICARE Encounter Data project—part of the Executive Information Decision Support (EIDS) program office—has been instrumental in getting the once-ailing Military Health System (MHS) back on its feet.

The TED application uses a solid hardware, OS and database foundation and health care industry-standard records to enable quality health care for millions of beneficiaries worldwide.

TRICARE is the $37 billion health plan for the Defense Department, responsible for the medical needs of more than 9 million military personnel, veterans and their families. TRICARE has its own direct-care network, but also relies on a global network of civilian health professionals, hospitals, pharmacies and suppliers (referred to as “purchased care”).

Revolutionary system

Unfortunately, in the 1990s, these purchased-care providers were deserting the system in droves. Claims processing based on the old Healthcare Service Record was a cumbersome, paper-based, manual procedure that could take weeks to validate a claim—and longer to pay it.

TED records processing was congressionally mandated by the National Defense Authorization Act (NDAA), and came online in 2003, revolutionizing the TRICARE system. “We built TED on an industry-leading platform,” said Lt. Col. Robert Aarhus, EIDS program manager.

The platform includes IBM hardware servers, AIX operating system and DB2 database. The system also uses COTS data connectivity, analysis and reporting software, such as Power Center from Informatica Corp. of Redwood City, Calif., BusinessObject from Business Object Inc. of San Jose, Calif., and Connect Direct from Sterling Commerce of Herndon, Va. Many of these components rank high in analysts’ opinions, suggesting that the chosen technology will continue to prove itself for years to come.

A keystone of the system is its compliance with security and privacy mandates. Maintaining strict accountability to DOD, Health Insurance Portability and Accountability Act and other directives is essential for such a large system containing information on so many people. Encryption, data transfer safeguards and controlled access to records are all part of the constraints.

Speedy process

The new TED system handles 90 percent of claims within 24 hours, a rate that far exceeds the health industry average of 69 percent of electronic claims processed within seven days. Providers also can track their claims immediately after submission. The system rapidly posts payments and denials, and systematically follows up on unpaid claims. Most reimbursements are paid within 30 days, which permits shorter billing cycles.

“This automated, prompt processing encourages more health providers to accept and treat TRICARE beneficiaries,” Aarhus said.
eter O'Neal, Steve Lewkovich, Jeffrey Lopata, Clarence Williams, Lt. Col. Robert Aarhaus, and Kevin Donohue
Image: Rick Steele
The tricare encounter data project team: From left, Peter O'Neal, Steve Lewkovich, Jeffrey Lopata, Clarence Williams, Lt. Col. Robert Aarhaus and Kevin Donohue
Since more providers are willing to accept TRICARE patients, quality health care is becoming more accessible to MHS’ 9.2 million beneficiaries worldwide. That translates into a higher level of health overall for the program. This, in turn, makes it easier to maintain good health.

More news on related topics: Business Process Management, Defense IT, Health IT, Management, IT Management



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