Veteranclaims’s Blog

March 25, 2009

Time required to rate a claim, testimony before Congress

Filed under: rating clai; Congress; QTC Management; — veteranclaims @ 9:15 pm

House Committee on Veterans’ Affairs
November 19, 2008, at 10 a.m.
Roundtable Discussion on Issues Concerning Our VeteransStatement of Marjie Shahani, M.D. Senior Vice President, Operations QTC Management, Inc., Diamond Bar, CA

Testimony before Congress on claims processing. QTC interviewed experienced claims examiners and asked them to break down the process and allocate time for each step in the rating process, assuming 7 claimed conditions.

The four steps of the rating process and allotted times were:

1. Initial review of the c-file: 20 minutes.
2. Linking the evidence in the file to the claimed conditions: 85 minutes.
3. Determining the severity of the condition and if each is service connected: 40 minutes.
4. Writing the rating decision: 65 minutes.

The total time to examine a veteran’s claim is 210 minutes or 3.5 hours.
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http://veterans.house.gov/hearings/Testimony.aspx?TID=30555&Newsid=179&Name=%20Marjie%20%20Shahani,%20M.D.
House Committee on Veterans’ Affairs

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November 19, 2008, at 10 a.m.
Roundtable Discussion on Issues Concerning Our Veterans

Hearings » The Use of Artificial Intelligence to Improve the U.S. Department of Veterans Affairs’ Claims Processing System
Statement of Marjie Shahani, M.D.
Senior Vice President, Operations
QTC Management, Inc., Diamond Bar, CA

Mr. Chairman, Members of the Subcommittee, thank you for the opportunity to testify before you today on this important topic of claims processing. QTC is a nationwide, private provider of medical examination and medical record services to the medical and disability communities, including federal, state and local government agencies; property and casualty insurance carriers; third-party administrators; employers – and the claimants they serve. With 580 highly-trained employees located at five strategically-placed regional administrative offices, 35 owned and operated medical facilities in seven states, and more than 12,000 pre-screened medical professionals, QTC has produced more than 2.5 million quality medical exams and reports over the past ten years and pioneered software and technology to ensure quality, timely, customer-focused and cost effective services for our clients throughout our 25 years of experience.

QTC Experience with VBA C&P Process

QTC has been a provider of C&P examinations to the Veterans Benefits Administration (VBA) since 1998. QTC provides medical examinations to veterans and active duty service members seeking compensation from the VBA in 12 VA Regional Offices (VAROs) and 40 Department of Defense (DOD) Benefits Discharge Determination (BDD) sites around the country. After completing the medical exam, QTC provides a detailed narrative report according to the guidelines of the VA’s Automated Medical Information Exchange (AMIE) worksheets. VA’s rating specialists then use this information along with the veteran’s claim file, or c-file, to adjudicate the veteran’s claims. Supporting the VBA for the past nine years has provided QTC with an in-depth understanding of the complexity of the activities, nuances and uniqueness of the VA medical disability examination process, as well as its challenges.

QTC Developed Software Applications to Support the C&P Process

QTC has applied its experience and expertise in developing knowledge-based tools and technology, not as the company’s primary purpose, but to facilitate and streamline the work of QTC’s medical professionals and support staff.

Specifically for veterans’ C&P medical examinations, QTC has developed:

* A Client Portal – an Internet-based application specifically designed and written for VA Central Office, VAROs, and DOD. This application provides VA and DOD with online access to the status of each case and appointment details along with the exam results, including the narrative report and diagnostic test results, and provides the ability to review the progress of any case, review management reports, case summaries and perform a batch report download from a secured Internet connection.
* A Protocol Engine – A medical exam protocol engine, or software, that synthesizes multiple VA required AMIE worksheets with portions of the VA rating schedule (38 CFR, Part 4) into one veteran specific medical examination form, thereby providing examiners with a single head-to-toe examination. It organizes the VA requirements into a form that assures the physician will address each and every medically claimed condition for each veteran. This software generates a specific exam protocol based on VA AMIE worksheets and the veteran’s claimed conditions, and it allows for immediate updating to conform to VA statutory, regulatory and medical changes and quick dissemination to all providers nationwide.

A Logical Next Step – Organize the Evidence

Secondary to our nine years of experience working with VA, we acknowledge the complex challenges of the VA medical disability process – it is like no other disability program we have worked with previously. In an attempt to provide value-added services, QTC applied its knowledge and experience to the next step in the C&P process- specifically simplifying and streamlining the information gathering process for the rating specialists so that they are able to rate the veteran’s claim in a quality, timely, customer-focused and cost-effective manner.

QTC developed an Evidence Organizer (patent-pending) – a working prototype that is an automated rating tool designed to assist the VA rating specialist and significantly reduce the time to determine a rating decision. The Evidence Organizer has great potential to help rating specialists search and find relevant information needed to determine and rate claims and thus help the VBA facilitate the process of adjudicating each claim.

Current Rating Process Productivity and Challenges

The rating process begins when a veteran files a claim. The VA Triage Team identifies the type of disability claim. Then the VA Pre-Determination Team determines the need for additional information, such as a medical examination, and gathers the additional records. Once all the evidence is gathered, the Rating Team reviews the entire contents of the c-file and rates the veteran’s claim, determining entitlement to benefits and the degree of disability. The Evidence Organizer was designed to assist the rating specialist in their process of reviewing the entire contents of the c-file and to assist them in making that final decision.

Currently, the VA goal for each rating specialist is to rate an average of 3-4 cases per day. In 2006, QTC interviewed experienced claims examiners and asked them to break down the process and allocate time for each step in the rating process, assuming 7 claimed conditions. The four steps of the rating process and allotted times were:

1. Initial review of the c-file: 20 minutes.
2. Linking the evidence in the file to the claimed conditions: 85 minutes.
3. Determining the severity of the condition and if each is service connected: 40 minutes.
4. Writing the rating decision: 65 minutes.

The total time to examine a veteran’s claim is 210 minutes or 3.5 hours. It becomes evident that a rating specialist cannot meet a target of 3-4 cases per day in one 8-hour workday. In fact, the actual average number of cases a rating specialist can process in one day is 2-3 cases.

In 2007, based on QTC’s data, the average number of conditions claimed per veteran was 4 for C&P cases and 8 for BDD cases. Examples of multiple-claimed conditions include left knee pain, asthma, low back strain, foot fungus, hearing loss, and depression. Additionally, reopened claims now account for 54% of all open cases, and cases are being reopened with additional unclaimed secondary conditions, such as hypertension, headaches, or scars.[1]

The biggest challenge the rating specialist faces is finding the medical evidence in the veteran’s paper files supporting the claimed conditions and linking the evidence to the appropriate rating code as listed in the 38 CFR, Part 4. QTC’s Evidence Organizer would eliminate this challenge, allowing the rating specialist to more efficiently make the rating determinations. The Evidence Organizer accomplishes this by creating an organized electronic c-file, providing the rating specialist the ability to quickly search and review all available evidence at the click of a mouse. The rating specialist no longer needs to review the entire c-file over and over again for each claim they are rating as the Evidence Organizer has organized all the available evidence for them.
stack of papers arrow screenshot of an electronic medical record

Potential Impact

The Evidence Organizer decreases the decision time to rate veterans claims from 3.5 hours to 2.2 hours, a time savings of 37% per decision, increasing the number of veterans’ cases rated from 2 per day to 3 per day. On an annual basis this would increase the number of claims decisions per rating specialist to 711 from the current 533, an increase of 178 decisions per rating specialist or a 33% increase.

Evidence Organizer Process

The Evidence Organizer can be applied to all four steps in the rating process, decreasing time spent per case file by organizing and highlighting all medically related information. The Evidence Organizer works by converting the cumbersome paper-based claim file (c-file) to create an electronic record or file (e-file). This document management process begins with a Technician scanning in the c-file and other hand written documents through the use of Optical Character Recognition. The software transforms each record into a text searchable digital record. As additional records become available they are also integrated into the e-file. At the heart of this process is QTC’s core knowledge database, which is built upon our extensive disability examination experience supporting the VBA C&P examinations.

The knowledge database identifies, highlights and electronically indexes all keywords and claimed conditions, for example: diabetes, asthma, arthritis, as well as any potential claimable conditions throughout each record, thereby providing the rating specialist with all possible claimable conditions. Once the e-file has been established, each record is reviewed to validate the software’s indexing, creating an initial table of contents for the e-file.

The next step involves a Reviewer validating the highlighted records and linking the referenced medical evidence to the VA rating requirements in 38 CFR, Part 4. PDF scanned records not compatible with electronic screening methods (handwritten records) are reviewed page-by-page by the Reviewer and relevant information is highlighted, extracted, and digitally-indexed and linked to the rating criteria appropriate for the claimed condition or potentially claimable condition. Once all the records have been reviewed the software creates a full and complete e-file with a table of contents listing all claimed conditions.

Finally, the complete annotated e-file is electronically available for the VA rating specialist to review and assist in their rating decision process. The software suite allows the VA rating specialist to:

* Review and search each and every document at the click of a mouse.
* Review all tagged, annotated and associated data.
* Add the rating specialist’s determination of relevance with rationale electronically.
* Identify, tag and index additional information as desired.
* Document the rating decision made with the referenced evidence.
* Review any additional potentially claimable conditions

Summary

By applying new technologies such as the Evidence Organizer, the VBA could:

* Organize medical evidence.
* Reduce routine and repetitive tasks.
* Increase accuracy by facilitating cross-referencing.
* Link the rating criteria with the clinical annotation.
* Scan, index and review all medical records.

Also, The Evidence Organizer will potentially complement RBA-200 or other existing VBA software and serve as a training tool. With the current challenges the VBA is experiencing in claims processing, the application of this technology is essential to improving performance and efficiently providing veterans with accurate ratings.

[1] Statement of Mr. Ronald R. Aument before the House Committee of Veterans’ Affairs, March 13, 2007.
Subcommittees

* Disability Assistance and Memorial Affairs
* Economic Opportunity
* Health
* Oversight and Investigations

House Committee on Veterans’ Affairs
335 Cannon House Office Building
Washington, D.C. 20515
(202) 225-9756

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