软件bug 索赔_索赔提交管道

软件bug 索赔

Medical claims data is complicated, like much of the US healthcare system. But that just means that the opportunities available from leveraging this important dataset in useful ways are all the greater. This extended series of articles will help make sense of medical claims datasets for those new to using them — what the many fields mean, what information they hold, and what kinds of interesting questions you can answer using them and how to do that.

与美国许多医疗保健系统一样，医疗索赔数据也很复杂。 但这仅意味着，以有用的方式利用这一重要数据集的机会就更大了。 扩展的文章系列将帮助您了解那些刚使用它们的医疗要求数据集-许多领域的含义，它们所持有的信息以及您可以使用它们回答的哪些有趣的问题以及如何做到这一点。

医疗索赔数据从何而来 (Where Does Medical Claims Data Come From)

Medical claims datasets are the final step in a long process. It can be helpful to understand this process (we’ll call it the “claim submission pipeline”) for several reasons:

医疗索赔数据集是漫长过程中的最后一步。 出于以下几个原因，了解此过程可能会有所帮助(我们将其称为“索赔提交管道”)：

• Data Integrity: like all datasets, healthcare claims data contains errors and inaccuracies. Understanding where those errors may enter the data can help diagnose and remediate them. Additionally, sometimes data that looks erroneous can be an indicator of fraud or other malfeasance, and understanding the claims submission pipeline can help distinguish between intentional and unintentional data integrity gaps.

  数据完整性 ：与所有数据集一样，医疗保健索赔数据包含错误和不准确性。 了解这些错误可能在何处输入数据可以帮助诊断和纠正它们。 此外，有时看起来错误的数据可能表示欺诈或其他不当行为，了解索赔提交渠道可以帮助区分有意和无意的数据完整性差距。

• Understanding Data: there are lots of conventions embedded in medical claims data, and there are many competing incentives that get sorted out using those conventions. Knowing these rules helps you understand why your data looks the way it does. Listing those “unwritten rules” out is part of why I’m writing this series.

  了解数据：医疗索赔数据中嵌入了许多约定，并且使用这些约定可以梳理出许多相互竞争的诱因。 了解这些规则可以帮助您理解为什么数据看起来如此。 列出那些“不成文的规则”是我编写本系列文章的一部分。

• Application: the insights you gain from data will hopefully be implemented to better the healthcare system. The claim submission pipeline drives financial payment of providers (and costs for insurers/payers) so the claim submission pipeline can be a good summary view of the whole healthcare system (“follow the money” is good advice when analyzing medical claims data).

  应用：您将从数据中获得的见解将被实施，以改善医疗保健系统。 索赔提交管道推动了提供者的财务付款(以及保险人/付款人的费用)，因此，索赔提交管道可以成为整个医疗系统的良好摘要视图(“分析金钱”是分析医疗索赔数据时的好建议)。

索赔提交管道 (Claim Submission Pipeline)

步骤1)临床事件 (Step 1) Clinical Event)

Medical coding starts at the time of care with documentation in the medical record. This text-based document is the source of truth for understanding the clinical event. This record gets turned into the claims forms that in turn become medical claims data.

医疗编码始于护理时，并带有医疗记录中的文件。 这份基于文本的文档是了解临床事件的真实来源。 该记录被转换成索赔表，这些表又变成医疗索赔数据。

To get a flavor for the type of information included in the medical record: the National Committee for Quality Assurance (NCQA) is an independent accreditation organization for physicians and health insurers. The NCQA offers the following 6 core components of medical record documentation:

要了解医疗记录中包含的信息类型，美国国家质量保证委员会(NCQA)是一个独立的医师和健康保险公司认证机构。 NCQA 提供以下六个病历文档的核心组成部分：

• Significant illnesses and medical conditions are listed
  列出了重大疾病和医疗状况
• Medication allergies and adverse reactions are prominently noted (or absence there of)
  药物过敏和不良React特别突出(或不存在)
• Past medical history for recurring patients is easily identified and includes serious accidents, operations, and illnesses.
  很容易确定复发患者的过去病史，其中包括严重的事故，手术和疾病。
• Diagnose that are consistent with findings
  与发现一致的诊断
• Treatment plans that are consistent with diagnoses
  与诊断一致的治疗计划
• No evidence that a patient is placed at inappropriate risk by a procedure
  没有证据表明该程序使患者处于不适当的风险中

The medical record itself has not historically been the subject of data analysis, both because it was stored in written form (not easily digitized) and is text-based (more difficult to analyze), however with the enhancement of optical character recognition and natural language processing tools in recent years, the medical record is proving to be very useful data for analysis. For now

从历史上看，病历本身并不是数据分析的主题，这既是因为它以书面形式存储(不容易数字化)又是基于文本的(更难分析)，但是随着光学字符识别和自然语言的增强近年来，医疗记录处理工具被证明是非常有用的分析数据。 目前

步骤2)提交申诉 (Step 2) Claim Submission)

Medical coders are healthcare professionals who translate the information contained in the medical record into standardized forms which become the basis for the medical claims dataset.

医疗编码员是医疗保健专业人员，他们将医疗记录中包含的信息转换为标准化形式，这些形式成为医疗索赔数据集的基础。

There are two main claim forms, the CMS-1500 and UB-04. The CMS-1500 claim form is used by for billing individual physicians services, while the UB-04 is used for billing facility services — the CMS-1500 describes is used by a person, the UB-04 is used by a building/institution.

主要有两种索赔形式，CMS-1500和UB-04。 CMS-1500索赔表用于为个人医生服务开票，而UB-04用于开具账单服务-CMS-1500描述的是人使用的，UB-04是建筑物/机构使用的。

For a standard hospital visit, there are 2 claim forms submitted — a CMS-1500 by the doctor who provided care during that visit, and a UB-04 by the facility who furnished the equipment, laboratory/radiological services, etc.

对于标准的医院就诊，提交了2份索赔表-在就诊期间提供护理的医生提供的CMS-1500，以及提供设备，实验室/放射学服务等的设施的UB-04。

Sometimes these forms are just referred to as “CMS” and “UB”. The CMS form is also called the “HCFA” — CMS stands for “Centers For Medicare and Medicaid Services”, a federal agency which used to be called the “Health Care Finance Administration”.

有时，这些形式仅称为“ CMS”和“ UB”。 CMS表格也称为“ HCFA”-CMS代表“ Medicare and Medicaid Services中心”，这是一个联邦机构，以前被称为“ Health Care Finance Administration”。

Almost all claims are filed electronically now — the 837-P and 837-I forms are the electronic version of the CMS-1500 and UB-04, respectively (“P” and “I” for “professional” and “institutional”).

几乎所有索赔现在都通过电子方式提出-837-P和837-I表格分别是CMS-1500和UB-04的电子版本(“ P”和“ I”分别代表“专业”和“机构”)。

Medical coders are often credentialed. The three most common credentials are the Certified Professional Coder (CPC), the Certified Coding Specialist (CCS) and the Certified Medical Coder (CMC) credentials. The CPC and CMC certifications are most common for coders working in a physician’s office or outpatient clinic, while the CCS certification is common for coders working in an inpatient setting.

医疗编码员通常具有证书。 三种最常见的凭据是认证专业编码员(CPC)，认证编码专家(CCS)和认证医学编码员(CMC)凭据。 CPC和CMC认证对于在医生办公室或门诊诊所工作的编码员最为普遍，而CCS认证对于在住院环境工作的编码员最为普遍。

There are many specialized coding certifications offered by the AAPC (American Academy of Professional Coders) and AHIMA (American Health Information Management Association). There is currently no requirement that individuals submitting medical claims be credentialed, however employers of medical coders often require it.

AAPC(美国专业编码学会)和AHIMA(美国健康信息管理协会)提供了许多专业的编码认证。 当前没有要求提交医疗要求的个人的资格证书，但是医疗编码人员的雇主经常需要此证书。

第3步：索赔裁决 (Step 3) Claim Adjudication)

Providers send the completed claim form (837 file) to any payers the patient is covered by. A “payer” is any entity that provides insurance to the patient (they “pay” part or all of the healthcare costs for the patient). This can be a commercial health plan, Medicare, or Medicaid, including Medicare Advantage and Medicaid Managed Care plans which are run by commercial insurance companies on behalf Medicare and Medicaid (types of payer organizations in the US will be the subject of a future article).

提供者将填写好的索赔表(837文件)发送给患者所覆盖的任何付款人。 “付款人”是为患者提供保险的任何实体(他们为患者“支付”部分或全部医疗费用)。 这可以是商业健康计划，Medicare或Medicaid，包括Medicare Advantage和Medicaid Managed Care计划，这些计划由商业保险公司代表Medicare和Medicaid运行(美国的付款人组织类型将在以后的文章中讨论) 。

Each type of payer has rules about how they will process claims. Claims processing by a payer is a complicated interface of these rules. We will cover this area in much greater detail in future articles, because after the initial coding, this is the most active step in the claims pipeline. For now, note that the payer will take the following items into consideration during claims processing:

每种付款人都有关于如何处理索赔的规则。 付款人的索赔处理是这些规则的复杂接口。 我们将在以后的文章中更详细地介绍这一领域，因为在进行初始编码之后，这是索赔流程中最活跃的步骤。 目前，请注意付款人在理赔过程中将考虑以下事项：

• Covered Benefits — most payers exclude services which are not medically necessary, such as cosmetic procedures or “off-label” treatments or prescriptions. Sometimes these rules vary by state — fertility treatments, for example, are mandated to be covered benefits by 19 states.

  承保的福利 -大多数付款人都排除了医疗上不必要的服务，例如整容手术或“非处方”治疗或处方。 有时，这些规则因州而异-例如，19个州规定生育治疗必须包括福利。

• Correct Coding — payers will review the submitted claim to ensure the codes are used correctly. For example, some diagnosis codes are not allowed to be used as a primary diagnosis in any circumstance (don’t worry if those terms don’t make sense quite yet — we’ll dive into much greater detail there). Payers may also request the medical record and verify that it supports the coding on the claim.

  正确编码 -付款人将审查提交的索赔，以确保正确使用编码。 例如，在任何情况下都不允许将某些诊断代码用作主要诊断(不要担心，如果这些术语还没有意义的话，我们将在其中进行详细介绍)。 付款人还可以要求病历并验证其支持索赔中的编码。

• Provider Contracts and Reimbursement Policy — payers sign contracts with many providers (called “in-network”, “participating”, or “par” providers) which dictate what they payer will provide as reimbursement for services. Providers without a contract with the payer are called “out-of-network”, “non-participating”, or “non-par” providers) — while no contract is signed, payers have rules about how they will reimburse these providers.

  提供商合同和报销政策 -付款人与许多提供商(称为“网络内”，“参与”或“同等”提供商)签订合同，这些合同规定了付款人将提供什么作为服务报销。 与付款人没有合同的提供者称为“网络外”，“非参与”或“不平等”提供者)-尽管未签订任何合同，但付款人有关于如何偿还这些提供者的规则。

• Prior-Authorization — some medical procedures require pre-approval by the payer before care is given. Payers will validate that this pre-approval was given.

  事先授权 -有些医疗程序需要付款人预先批准才能给予护理。 付款人将验证是否已提供此预先批准。

• Coordination of Benefits/Subrogation — if a patient is covered by two health insurance policies, there are rules for which policy pays which costs (called “coordination of benefits”). Medical costs that arise from accidents or injuries which are covered by another type of insurance policy, such as an automobile or workers compensation policy, are not reimbursable medical insurance expenses under most circumstances (called “subrogation”).

  利益/代位的协调 -如果患者有两项健康保险保单，则有规则规定该保单支付哪些费用(称为“利益协调”)。 由事故或伤害引起的医疗费用在另一种类型的保险政策(例如汽车或工人赔偿政策)中涵盖，在大多数情况下都不属于可偿还医疗保险费用(称为“代位”)。

• Fraud — healthcare fraud is a significant issue, and payers work hard to ensure that fraudulent providers are not reimbursed. Examples of fraudulent billing behaviors are billing for services not provided, falsifying medical record documentation, and billing egregiously high fees.

  欺诈 -医疗保健欺诈是一个重要问题，付款人必须努力确保欺诈性医疗服务提供者不予报销。 欺诈性计费行为的示例包括：对未提供的服务计费，伪造病历文档以及计费高昂。

Providers have a right to appeal the decisions made the provider during claims processing. As such, claims processing can be an iterative process: a provider may submit a claim, the payer requests the medical record, the payer denies a portion of the claim due to insufficient medical record documentation (called a “line item denial” because only certain “lines” on the claim were denied, not the full claim), the provider appeals the denial and provides amended medical record documentation, the payer overturns the denial on appeal and reimburses the full claim.

提供者有权对索赔处理过程中提供者的决定提出上诉。 这样，索赔处理可以是一个反复的过程：提供者可以提交索赔，付款人要求病历，付款人由于病历文档不足而拒绝了一部分索赔(称为“拒绝行项目”，因为只有某些索赔中的“行”被拒绝，而不是全部索赔)，提供者对拒绝提出上诉并提供经修改的病历文件，付款人推翻上诉中的拒绝并偿还全部索赔。

步骤4)索赔数据库 (Step 4) Claims Database)

The claims processing system will provide data files to a claims database, which will house historical claims data for future analysis. The data sent by the claims processing system will include all of the information included on the claim form, but also a number of other items, including:

索赔处理系统将向索赔数据库提供数据文件，该数据库将存储历史索赔数据以供将来分析。 索赔处理系统发送的数据将包括索赔表中包含的所有信息，还包括许多其他项目，包括：

• Member Information — the claim form includes a member’s name and policy ID number, but the payer also maintains additional information about a member, including demographic information (age/gender), policy/product type, and employer. This additional data will be stored in the claims database in a way that easily joins to the claim data.

  会员信息 -索赔表中包含会员的姓名和保单ID号，但付款人还维护有关会员的其他信息，包括人口统计信息(年龄/性别)，保单/产品类型和雇主。 这些附加数据将以易于加入索赔数据的方式存储在索赔数据库中。

• Provider Information — similar to member information, a provider’s identifiers (Tax ID/TIN, National Provider Identifier/NPI) are provided on a claim but payers maintain additional information, such as practice group name, specialty, and credential status (e.g. MD, DO, LCSW, etc.).

  提供商信息 -与会员信息类似，在索赔上提供了提供商的标识符(税号/ TIN，国家提供商标识符/ NPI)，但付款人保留了其他信息，例如业务组名称，专业和凭证状态(例如，医疗数据，待办事项，LCSW等)。

• Code Description Tables — the codes used on a medical claim form (CPT, Modifier, ICD-10 CM/PCS, DRG, Revenue Code, etc.) are not always easy to analyze on their own, so claims database often include mapping tables which group similar types of codes together and provide useful definitions. For example, a CPT description table might group the ~320 CPT codes between 00100 and 02020 that are used for Anesthesia services together.

  代码说明表 -医疗索赔表上使用的代码(CPT，修改器，ICD-10 CM / PCS，DRG，收入代码等)并不总是很容易自行分析，因此索赔数据库通常包括映射表，将相似类型的代码组合在一起，并提供有用的定义。 例如，CPT描述表可能会将00100到02020之间的〜320个CPT代码分组在一起，这些代码用于麻醉服务。

• Claims Processing Information — the processing system may pass on information about why it processed a claim the way it did. For example, this code field may indicate “denied due to insufficient clinical documentation”, or “non-par reimbursed at 150% of CMS”.

  索赔处理信息 -处理系统可能会传递有关其为何处理索赔的信息。 例如，此代码字段可能指示“由于临床文献不足而被拒绝”，或“在CMS的150％处未偿还部分”。

步骤5)分析 (Step 5) Analysis)

This is where you, the target audience of this set of articles, starts having fun: you pull data from the claims database and begin to analyze it. Understanding how this data got into the database can be the key in making sure that analysis can be used the make the US health system work better.

在这里，您是这组文章的目标受众，开始玩乐了：您从索赔数据库中提取数据并开始进行分析。 了解这些数据如何进入数据库是确保可以使用分析以使美国卫生系统更好运转的关键。

Please leave any questions, requests for new topics, or other comments below — I look forward to hearing from you!

请在下面留下任何问题，对新主题的请求或其他评论-我希望收到您的来信！

翻译自: https://towardsdatascience.com/the-claims-submission-pipeline-fbe8fb9c0f19

软件bug 索赔