Access Innovations Integrity Initiative (AI³)

The problems:

  • The challenges involved in shifting through an ever increasing flow of data are creating enormous potential for fraud within the health care fields.

  • The already enormous risk to government agencies trying to make timely and proper payments while avoiding scam artists continues to grow.

  • The players must police the steadily increasing avalanche of data without sacrificing integrity. The constantly rising cost of compliance affects the quality of the audits designed to monitor care quality and speed of delivery to the patient.

  • By 2013 all organizations need to change from the complicated 4,000+ code system of the ICD-9 to something over 30 times more complicated in the ICD-10 140,000+ code system.

  • Many players in many roles need to reach the same objective, but they are divided by different regions, with disparate agencies all overseeing some portion of this tangle of requirements and complex, overlapping regulations.

The solution:

Automation can provide consistent, uniform, auditable, and replicable reporting, error flagging, and trend analysis to the many organizations involved. The reports needed are based on the same data, but require flexible outputs depending on the organization. A hospital or medical group will need one kind of report to show their risk factors and where they need to pay more attention, surfacing potential problem areas. Payment and auditing organizations need to see flags of potential fraud quickly before it blossoms into a major loss for the taxpayers. Tracking systems for compliance do much of this work, but they are not able to zero in on the potential problem areas.

The Access Innovations Method (AIM) starts with workflow analysis and consulting to structure a full audit-trigger analysis system using an automated rules-based approach. We use this approach so that the audit – whether internal or external - will be able to see exactly why something surfaced and dig down into the results. Fully statistical approaches to the data based on vectors and co-occurrence can only work with a static set of data. When more data is added the vectors change, giving different results to the user the next time the data is run. In order to provide reliable, consistent, replicable, audit-testable results, we take the AIM approach.

The Access Innovations Integrity Initiative (AI³) system is built on a suite of tools and services we have used successfully in support of enterprise, government, and scholarly publishing for the last 33 years. The five main components are detailed in the table below. They include the Code Integrity Service (CIS), Governance Mapping (GM), Validation and Cross Checking (VCC), and the Enriched Content Mapping Solution (ECMS).

Access Innovations Integrity Initiative (AI³) Products and Services
Product / Service

Who Can Use It?

 How Is It Available? What Kinds of Documents Does It Process? How It Works Display / Delivery of Results
Code Integrity Service (CIS) Service bureaus Fee license or item passed through the system Any text or coded materials: Doctor notes, organization names, memorandum, HIPAA statements, etc. MAIstro® with ICD-9 and ICD-10 rules bases. In-field rules applied to provide practice type or doctor, by organization, by date, by city, and so forth. Report of email traffic by unit and date. Shows where the organization is at risk in audit discovery.
Governance / Monitoring Top 100 hospitals Monthly subscription or yearly audit Email, correspondence, records management, policies Semantic Verification Mapping (SVM). Fear of risk factors. Service-to-code QA verification. Runs M.A.I.™ on all text and shows results of code indexing. Report of all document activity by unit and date. Shows where the organization is at risk in audit discovery.
Validation and Cross Checking RACs and audit MICs License or fee and maintenance or report purchase Full text of notes and all documents Using inline tagging to flag the spot within a document where the code is applied and therefore the "smoking guns" for audit investigation. Validation and code checking to support go/no go decisions in intelligent audit support. Taking hospital data, for example, and running a report to see how close they are in compliance. “Red meter to green meter” results given by assessing the percentage of errors in the coding based on the M.A.I.™ returns against the actual coding done.
Enriched Concept Mapping Solution (ECMS) Insurance companies, large audit firms embedded in their software, service bureaus OEM embedded in software or as a service Domain and unstructured data in addition to all documents and databases Term Trend Analytics (TTA) based on the rules for the ICD-9 and ICD-10 Concept Mapping. Allows discovery through visualization of the main directions of the firm. Flags areas that require further investigation. Gives the user a graphical interaction as the user experience (UX) rather than the traditional many line report. Depends on the rules, thesaurus synonyms, term cross-references, and other references, supplemented by MeSH. Scatter diagrams showing the distribution of the information. Data maps of the real time data shown in an interactive visual display.
Access Innovations Method (AIM) Any company $2000 per day plus expenses Workflow analysis and consulting to structure a full audit trigger analysis system using automated rules based methodologies. Workflow analysis and a map for how to implement.