Progress | Innovations

Constant evolution

Refined Innovations

Suite of eServices

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Palmetto GBA continues to expand tools on our industry leading provider portal to include trend reporting, multiple provider comparative reports, and other devices to assist groups and individual providers with their Medicare business analytics. We’re now leveraging this suite of products and their use by providers to develop our Provider Behavior Analytics Engine (PBAE). PBAE goes beyond the typical outlier analytics and uses their interaction with these new analytic tools to allow a provider to either self-correct or self-select themselves for additional interventions. Our portal efforts remain highly visible with our customers, and we work closely with them to define new requirements and look for additional features to develop.
 

Debt Management System (DMS)

Palmetto GBA seeks to modernize Medicare debt management activities. In 2017, DMS improved automated data entry processes, augmented system response and enhanced error handling. These modifications resulted in heightened system productivity and more efficient handling of processing errors. In addition, system-wide flags were implemented to better integrate activities between operational areas and improve visibility of high-priority actions.

iDA (Intelligent Document Automation) Project

Palmetto GBA is further developing our ability to receive and process both the electronic and automated clinical data we receive from the provider community in support of medical review documentation requests, appeals and prior authorization. iDA includes the tools to facilitate automated adjudication.

iDA also includes implementation of Natural Language Processing (NLP) and Artificial Intelligence (AI) to assist a reviewer in making the clinical decision. While we do not expect to fully rely on NLP/AI engines to make clinical decisions, our goal simply is to become more effective reviewers. We’re currently reviewing and piloting several AI-based products supporting clinical decision making. These pilot projects, performed in conjunction with CMS’s Center for Program Integrity, are integral as we experiment and conduct research/development for the following solutions:

  • C.A.R.D. (Computer Assisted Review Decision) – uses AI based on Acceptable Use Criteria to provide immediate review and scoring of a home health Electronic Medical Record (EMR) to assist Medical Review in identification of claims with potential errors
  • iMarker – identifies and organizes critical text and required information for review
 
 

Enhanced Security Systems

The Centers for Medicare & Medicaid Services (CMS) has increased its focus on systems security and heightened its number of security requirements, including a 20 percent increase in controls to be implemented by September 25, 2018. To meet — and exceed — these expectations, Palmetto GBA remains committed to improved overall system security.

In the last year, Palmetto GBA made more than 15 enhancements to the Security Manager Application, including the ability to process the new JJ A/B MAC information. Continued automation has reduced audit issues, errors and costs associated with the controls, and we are planning further developments in 2018.

The IP-360 system security score provides CMS with a viable and base metric for measuring IT risk on our Medicare network. Maintaining an “A” is a strong indicator that Palmetto GBA’s patch and configuration management programs are working well, even considering the major challenges presented by Meltdown and Spectre.

IP-360 System Security maintained an “A” rating for the past 51 consecutive months.

 
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Innovations

Competitive advantage through enterprise-level innovations.

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