Hacking Medicare: Why we should use hacking as a method to solve some of our healthcare problems – Part 3

affordable-effective-healthcare

If you’ve read my other “Hacking Medicare” posts, you know that I’m talking about hacking for social good, not for nefarious purposes. If you missed those posts, check out Part 1 and Part 2.

“Look at all these cubes”  
It was the spring of 2005, an executive at a Medicare administrative contractor (MAC) led me to the center of a vast cube farm at his organization. Like rows and rows of Illinois corn, the cubes seemed to go on forever.

He turned to me and said, “Look at all of these cubes. If Medicare, and for that matter, this company, is to survive, we need to figure out a way to do this work faster, better and with fewer resources. For right now, I need to you to introduce automation into every operational process in every cube in six months. Get to work.”

Then he walked off.

20 workflows, 13 departments, 350 users, 20 weeks  
We had no road map, no time for new hires or new tools and the date could not move. And we had to be done by August 31.

We also could not use a traditional IT waterfall approach for designing and implementing the project, because it would simply take too long. So we named the project “Cheetah” and got to work. The Cheetah project would expand workflow/BPM into every operational team, a feat that would require the implementation of 20 workflows in 13 departments for over 350 users in five locations in just 20 weeks.

We needed a hack.

Why a hack? Why now?  
This may surprise those who think that Medicare is a slow-moving sloth that wastes billions while delivering less than stellar services, but the facts tell a vastly different story.

Simply put, Medicare is probably the most efficient and effective healthcare payer on the planet. Beneficiaries and Providers are satisfied with the program. They may grouse around small details on the fringes, but at its core, Medicare works very well.

At the time of my project, there were about 42 million Americans in the Medicare program. Cheetah could impact as many as 6.3 million beneficiaries and 130,000 providers.

It had to go well.

A really big MAC
The Centers for Medicare and Medicaid Services (CMS) administer Medicare. It does so by hiring private MACs to manage the administration of its programs in various regions. CMS ruthlessly bids on MAC contracts every five years. The Darwinian contracting process has dwindled the number of contractors to a hyper-efficient dozen or so players in 10 years.

Back in 2005, the MAC I was helping needed Cheetah’s efficiencies to effectively compete for their existing MAC contract. If they lost, 6.3 million beneficiaries and 130,000 providers would be calling another contractor. And a significant number of the MAC’s employees would be getting pink slips.

Cheetah needed to be a home run. No pressure.

Tune in to Part 4 to see if Cheetah ran successfully or limped off into the shadows.

Mike Hurley

Mike Hurley is the industry manager for Health Insurance at Hyland, helping health insurance organizations transform business processes that drive value for members, providers and employees. Mike works with current and prospective customers to use our award-winning product, OnBase, to drive business transformation. He is also responsible for our high-value, high-impact health insurance solutions, the like Mobile Medicare Enrollment Solution for OnBase. Prior to joining Hyland, he was the founder and president of Swim Lane Software, LLC. Hurley founded Swim Lane in 2007 to create a solution that leveraged Software as a Service (SaaS) technology to automate the processing and adjudication of Medicare Claims through unique use Business Process Management (BPM) and Business Rules Management Systems (BRMS) technologies. Preceding Swim Lane, he founded Green Square in 1997 as a national consulting practice that connected technology with business strategy. As a boutique services firm, Green Square was aimed at driving stakeholder value at over 25 BlueCross BlueShield plans in the U.S. Prior to Green Square, Hurley founded Avalon Technologies, Inc., an award-winning systems integrator focused on Enterprise Content Management (ECM), workflow and Optical Character Recognition (OCR) technologies.

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