1. THE MGPO Mission to Reduce administrative burden
ACT
Machine Learning, Coding Automation, and one Billing Office’s Venture into Software Development

2. MGH, other Partners entities, and PHS Private Affiliates
PBO Some Statistics
PROVIDERS
Provides Professional Billing services for over 8,000 service providers and 5,000 billing providers
SCOPE
MGH, other Partners entities, and PHS Private Affiliates
EMPLOYEES
~450 FTEs
AR DAYS (12/2017)
TOTAL CHARGES (FY17)
$3,977,221,287
TOTAL PAYMENTS (FY17)
$1,534,845,946 2

3. PBO Locations FOUR LOCATIONS: PBO North: Bedford, NH
PBO Boston: Brookline, MA
PBO Boston: Charlestown, MA
PBO South: Hingham, MA 3

4. Coder Environment Reasons for pursuing an automated solution
Coding represents a significant portion of cost
Three areas of professional billing coding: visit/procedure, diagnosis and billing rules
All or part these functions can be performed by different resources: providers, professional coders, billers, or natural language processing and machine learning options
Coders can be: employees (central or distributed) or independent contractors (on or offshore); a strong teleworking model exists
Recruitment and retention is a major challenge in providing a reliable service 4

5. Genesis of Our Journey ICM ICM MD ACT
Began looking to improve workflow and revenue in 2004
Initial focus was on Anesthesia
Internally developed 3 generations of tools
All are widely deployed within PHS
ICM
ICM MD
ACT 5

6. Developmental sequence
Integrated
Coding
Module
ICM
Coding Module
User Interface
ICM MD
Automated
Tool
ACT
PHASE 1
PHASE III
PHASE 1I 6

7. Phase 1: Integrated Coding Module
Live in 2005
Enhanced workflow, throughput and QA
Coders’ Workstation
Became the main engine for all other enhancements and initiatives 7

8. MGPO contracted w/Patient Keeper in the IP E&M space
PHASE II: icm md
Beginning in the late 1990’s numerous MGH/MGPO practices moved to electronic charge capture (OrthoDude, Voice Center, Speech Therapy, PT/OT, SquareKnot)
MGPO contracted w/Patient Keeper in the IP E&M space
Surgical charge capture is unique and we integrated SquareKnot with ICM to create ICM-MD
Better:
MD and practice workflow
Surgical schedule reconciliation
Increased revenue
Decreased costs 8

9. ICM MD’s Statistical Foundation
Raw Data
Clusters
Coding Scenarios
Provider Charge Capture
Coder QA 9

10. Data from Every Single MGH Physician Survey
Do Physicians Enjoy, Like, Look Forward To, Or Want To Be Involved In Charge Capture In Any Way, Shape or Form? 10

11. Phase III: Discovery Can ICM help in the E&M space?
In an effort to reduce the administrative burden associated with E&M coding, in 2013 we experimented with a commercially available Natural Language Processing (NLP) vendor:
Commercial products required too much analysis
Too brittle
Very format dependent
Only benefit was to the vendor 11

12. Phase III: Machine learning Automated Coding Tool (ACT)
In 2014 we began building our own product.
Core objectives:
No human involvement for code prediction
Not dependent on format of the note
Perform equal or better than commercial products
Scalability for volume and type of cases 12

13. ACT Automated Coding Tool
Internally develop an automated coding tool to remove the burden of coding from providers and eliminate challenges of leveraging a commercially developed product.
Time
Save
Coding Accuracy
Improve
Developed
Internally
Since coding is automated, providers no longer have to spend time manually coding activity.
Codes are predicted using complex algorithms that are applied to historical documentation at a practice/provider level, resulting in lower risk and increased coding accuracy.
Because the product has been developed internally, application performance has been optimized to meet the needs of the MGH/MGPO and PHS.
Internal development of the product offers flexibility for scope expansion, grater scalability, and is more reliable compared with commercial products that have been analyzed. 13

14. Act How It Works Provider completes clinical documentation.
Note is sent from Epic to ICM where ACT performs analysis and outputs the appropriate CPT, ICD-10 codes and modifiers.
If codes meet a 90% statistical confidence level, they are routed to ICM and then back to Epic for billing.
If codes fail to meet a 90% statistical confidence level, they are routed to a Coder to review for accuracy.
If codes are changed, ACT retains the updated coding data and “learns” so that it be applied to similar cases in the future.
Claim is finalized and submitted for processing.
Randomized QA is performed to ensure ACT’s learning and overall accuracy rates.
ICM has been integrated with Optum’s Claims Manager,
a key part in our success. 14

15. Act Scope EKG GI Live Newton-Wellesley Ambulatory MGH
North Shore Medical Center
In Process
Brigham and Women's Hospital
SURGICAL
Live
Gynecology (includes Reproductive Endocrinology and Infertility (REI), Urogynecology and Gynecology Oncology)
Thoracic Surgery
General Surgery
Weight Center
Community Surgery
Trauma
Oral Max
Plastic Surgery
Pediatric Surgery
Cardiac Surgery
Transplant Surgery
Urology
EKG
Live
MGH
Cooley-Dickinson Hospital
In Process
North Shore Medical Center
PHS-wide solution
RADIOLOGY
Live
Martha's Vineyard Hospital
Cooley-Dickinson Hospital
In Process
MGH
North Shore Medical Center
Spaulding Rehab Hospital
PATHOLOGY
Live
MGH
Possible
Brigham and Women's Hospital
E&M
In Process
Pilot FY18, Q2 15

16. Not all stats apply to all services lines and practices.
ACT Stats
PROVIDERS
IMPACTED
200+
REDUCED
LAG
TIME
ACCURACY RATES OF
100%
IDENTIFIED IN SOME
SURGICAL AREAS
CODER
PRODUCTIVITY
+5%
INCREASE
INCREASE OF
10%
IN # OF HCC CODES
MEASURED
ACCURACY RATES OF
>90%
IDENTIFIED ACROSS
GI AREAS
*Stats included have been measured across some service lines and some practices.
Not all stats apply to all services lines and practices. 16

17. Next Steps PHS Commercialization
Expand deployment: Radiology and Pathology
Enhance automation, reconciliation and reporting
Pilot in Ambulatory/E&M space
PHS
Form a LLC: non-PHS institutions
Combine ICM and/or ICMMD and/or ACT
In negotiations with one academic, many others have expressed interest
Vision: Auto-adjudication at the point of care
Commercialization 17

18. Questions
And feedback?

19. Thank you

20. Appendix

21. MGPO Professional billing office (PBO) About Us
MISSION
The Professional Billing Office is dedicated to providing the highest quality billing services and analytics for all its customers while striving to be the industry leader for patient satisfaction.
By empowering its talented staff and leveraging cutting edge technology, the Professional Billing Office optimizes revenue to support the ultimate mission of its customers by allowing providers to spend more time on patient care, teaching and research.
Coding and Charge Capture
Revenue Cycle Management
Business Intelligence Solutions
Patient Financial Services
New Business Initiatives
Billing Services and Reimbursement Analysis 21