Digital Government Government to Citizen

Transcription

1 2013 STATE IT RECOGNITION AWARDS Submitted for Category: Digital Government Government to Citizen Project Initiation Date: March 1, 2010 Completion Date: Implemented in October 2012 Contact Information: Gail Overhouse Chief Information Officer Employment Development Department (916) Carlos Ramos Secretary and Chief Information Officer California Technology Agency (916)

2 SECTION 2: EXECUTIVE SUMMARY The State Disability Insurance Online System (SDI Online) is one of the most complex technology transformations undertaken by the California Employment Development Department (EDD). This new system automates the nation s largest State Disability Insurance program, which is comprised of the Disability Insurance (DI) and Paid Family Leave Insurance (PFL) programs. The DI and PFL programs provide wage-loss benefits to workers for short-term disabilities, time to care for seriously ill family members or to bond with a new child. The system pays approximately $5 billion annually and significantly improves the processing of DI and PFL claims. It also expands access to services for claimants, medical providers, employers and voluntary plan administrators and improves benefits delivery to claimants and enhances the State s ability to detect and prevent fraud. The SDI Online greatly improves customer service to its beneficiaries. It automates manual claims processing and enables work to be done more efficiently. Within the first month of implementation over 60,000 claimants, medical providers, employers and voluntary plan administrators registered for an online account. As a result, 50 percent of the three million continued claim requests received annually by EDD are now being approved and benefit payments are being authorized without staff intervention. New algorithms are being used to crosscheck doctor and claimant information with other State databases and new business processes are being used to notify doctors of activity on their accounts. This has allowed the State to detect potential fraud before it happens, minimizing DI funds lost to claims that should not be paid. Additional tools and technologies help EDD s fraud unit quickly access a vast amount of claim information and respond better to changing business needs, policy or legislation. The SDI Online is an innovation, a best practice, and a notable advancement. It s the next step forward for case management systems. The SDI Online System s ability to allow multiple intake channels for the users to submit claims and then have those claims processed automatically, with no staff interaction, is an innovation for California s State DI program. Previously, all processing was manually performed now more than 400 business rules that take in over 1,000 input parameters have automated the eligibility determination process. Automating claims is also the next step forward in delivering exceptional customer service. Claimants now have the ability to submit their claim information 24/7 and have the system automatically determine their eligibility and provide payments the very next day. Prior to SDI Online, it could take two weeks before someone could get their claim approved and their benefit payment authorized. In addition to quicker pay cycles, EDD s customer service representatives now have more information at their fingertips when a claimant calls. The system captures all claim information in an easy-to-search format allowing the call center to quickly pull up the claimant s entire file with a few keystrokes.

3 SECTION 3: BUSINESS PROBLEM AND SOLUTION Problem The California Employment Development Department s (EDD) Disability Insurance (DI) program provides temporary wage loss benefits to workers with short-term disabilities, time to care for seriously ill family members or to bond with a new child. These programs were being operating with an outdated legacy system that required laborintensive, paper-based processes and many manual interventions. Providing timely DI program benefits and services is essential to minimize financial hardships to these individuals and families. The DI Branch processed one million claims and paid out $5 billion in benefits per year. The average processing time for an initial claim was 14 days from receipt of a complete form. Every claim had to be submitted on paper and often required DI staff to contact claimants or medical providers to either obtain missing information or return forms to them for completion and/or corrections. These additional steps caused delays of as much as two weeks in processing claims. To detect fraudulent activities, the DI Branch had to rely on claim examiner discovery, hardcopy reports, and the DI Fraud Hotline. The system-generated reporting was inflexible and limited, and the data was generally historical rather than up-to-date. DI program decisions were supported primarily through high-level reports, institutional knowledge, and information gathered in discussions and meetings. The system lacked real-time data to make decisions; therefore DI Branch staff were unable to measure the effectiveness of operations across all areas, including detection and prevention of fraud and abuse. Fraud detection was also difficult as examiners and DI Branch staff would have to be trained to review these hard copy reports for certain variations. This meant fraud was not always identified right away. Real-time reporting and access to information was a critical component needed to streamline DI processes and improving customer service. A solution was needed to improve claims processing and benefit delivery, and enhance fraud detection. Solution The State Disability Insurance Online System (SDI Online) has transformed California s DI program by automating the nation s largest State Disability Insurance Program. The system expands access to services for claimants, medical providers, employers and voluntary plan administrators, improves benefits delivery to claimants and enhances the State s ability to detect and prevent fraud. The SDI Online allows claimants to file for benefits online. The system s automated manual claims processing enables work to be done more efficiently through edits and business rules that promotes accuracy and completeness of information received directly by the claimant online. There are more than 400 business rules that take in over 1,000 input parameters to automate the eligibility determination process. Nearly 50

4 percent of the three million continued claims are now processed and paid without staff intervention. Claims that used to take up to two weeks for payment to be authorized can now be processed the same day they are submitted. The SDI Online fraud component uses business intelligence and decision support technologies to detect fraud, such as creating claim profiling. This functionality has the ability to flag claims for further review if they fit certain fraud parameters. The system also allows for fraud testing functionality where unexpected relationships, social security numbers, addresses and cross-matching patterns (e.g. Wage Records and Workers Compensation data) are examined to determine if a claim is potentially fraudulent. The SDI Online also has the capability to track medical providers with a past history of fraud, allowing the DI Field Office Integrity Specialists to leverage existing fraud reports, and make notes in the system regarding the file. The new solution also automatically selects a random number of claims for quality control review. Project Management The SDI Online project was executed in accordance with Project Management Institute best practices as well as California s Project Management Methodology. The project was delivered on time and within budget over a three-year period. At the peak of the effort, the project involved more than 150 staff from the state and the vendor community. Innovative approaches to execute the work and ensure success included: Iterative-incremental methodology implementing incremental software releases allowed business users to access the solution early on so changes could be incorporated in a way that did not change the fundamental design. Incorporating this usability feedback early also enabled the Project to keep the scope and timelines intact. Mock Go Live internal users simulated the business processes prior to Go- Live Splitting internal vs. external go-lives - allowed internal users to get comfortable with the system before external users came on board. Solution Architecture The SDI Online is a custom-built solution based on an n-tier service-oriented architecture, which makes it easier to modify and maintain the system while minimizing the impact on other system components, utilizing a set of tools and technologies to achieve the required functionality. The following industry-leading technologies and interfaces with external systems were implemented: State-of-the-art.Net based custom developed web based solution Identity Management to provide identity and access management Business Rules Engine (to automate eligibility determination) Real-time web service to interface with other state agencies (i.e. Department of Motor Vehicles)

5 Training and Outreach The EDD developed a comprehensive 1,600-page training manual to train the 1,200 internal users of the application and conducted 16 courses over eight weeks with an average of two weeks of classroom training per employee to get the department ready for the new system. The EDD educated the public and other potential users through multiple webinars, mass-mailings and web blasts, social media, and an updated EDD website. The department also partnered with EDD s Workforce Services Branch offices to provide guidance to SDI claimants and to reach out to medical providers throughout the state. Items such as posters, Tip Sheets, Online tutorials, YouTube videos and 40,000 mail kits to physicians, practitioners and their representatives were created to inform and guide potential users through the SDI Online process. These efforts yielded very positive results. Most medical providers and claimants are now filing claims electronically or using the Optical Character Recognition form. In addition, as more claims are now being filed online, call volumes and in-person visits to EDD offices have decreased. SECTION 4: SIGNIFICANCE The SDI Online completely transformed how the DI program operated. The program moved from a labor-intensive, manual paper-based system to an automated and integrated system. It not only replaced an outdated legacy system, it allowed for a complete business process transformation, significantly expanded access to services, improved the delivery of benefits to claimants, and enhanced the State s ability to detect and prevent fraud. It is among the most significant technology projects undertaken by the EDD and automated the nation s largest SDI program. The processing of DI and PFL claims was measurably improved and access was expanded for claimants, medical providers, employers and voluntary plan administrators. The SDI Online is the next step forward for case management systems. The SDI Online s ability to allow multiple intake channels for the users to submit their forms and then have those forms processed automatically is an innovation for the California State DI program. This allows staff to focus on more important issues like investigating complex eligibility determinations and potentially fraudulent claims. To give a sense of the size and magnitude of the change, the State moved from less than 100 screens to over 700 screens in the new system, thus capturing and making available far more data and functionality to users. Alignment with State and NASCIO Priorities SDI Online directly aligns with Governor Brown s priorities of improving state efficiency and improving service delivery to the Citizens of California. This project supports Objective 1.1 of California s IT Strategic Plan, Increase online service and information offerings and make them more accessible through mobile devices; Objective 1.3,

6 Enhance transparency, accessibility and openness through online and mobile solutions to promote informed participation by the public; and Objective 4.3, Enhance the value of state information through tools to increase the ease of collaboration and data analysis. SDI Online also supports NASCIO s priority of legacy modernization: enhancing, renovating, replacing, legacy platforms and applications, and business intelligence. SECTION 5: BENEFIT OF THE PROJECT The SDI Online has automated the processing of DI claims, reduced costs and replaced manual intervention with electronic communications. Prior to SDI Online, it could take two weeks before someone could get their claim approved and their benefit payment authorized. Now, claims go through as early as the same day they are received. There are now more than 400 business rules that take in over 1,000 input parameters to automate the eligibility determination process. The number of interfaces is also significant, with more than 120 interfaces to external systems at EDD and other State agencies. The major program and process impacts of SDI Online directly benefit the following key stakeholders: Claimants (Recipients of SDI Program benefits)- the system ensures that benefits are not delayed or prevented, provides an electronic alternative (online or Web-based intelligent forms) to filing paper claims, assures the HIPAAcompliant security and privacy of the personal information submitted, and provides faster access to claims processing information. Medical Providers- easier and greater flexibility in doing business with DI Branch staff by accepting information in formats that they use and providing several ways for them to submit information; assures the security and privacy of personal information submitted to DI Branch; minimizes opportunities for fraud at intake during claim processing and internal to DI; separates the medical provider information submission from the claimant s; and assures accurate identification of medical providers submitting information electronically. EDD Employees- key data entry is minimized; navigation of the system is simplified via the use of electronic file folders; processing of routine claims activity is automated; and incomplete documents are automatically rejected and routed for correction. In addition, workloads are now balanced and can be distributed by automated transfer of workload to other DIB offices and between claims examiners. Employers in California- provides an electronic alternative, via intelligent forms, to providing and receiving DI Branch paper forms.

7 The SDI claimants, medical providers, employers and voluntary plan administrators benefit from the implementation of SDI Online with the ability to apply and submit claim information online. Nearly 50 percent of the three million continued claim forms received annually by the DI Branch are being approved and benefit payments are being authorized without staff intervention, resulting in claims being processed faster and benefits being approved sooner. This increased efficiency in process benefits the DI staff by allowing them to focus more on claims that need manual intervention, and benefits the claimant by allowing them to receive a more timely response to their claims. The most recent SDI Online usage metrics, as of April 25, 2013, demonstrate the steady use of the system by all categories of users. Total number of forms filed: 1,500,427 Total number of claims processed: 416,817 Number of claimant online accounts: 321,552 Number of medical provider/representative accounts: 14,683 The SDI Online also manages fraud and abuse through the implementation of HIPAA Administrative Simplification guidelines, which includes automated programs and business logic to combat fraud. In addition, automated integrity alerts to claims examiners provides improved fraud detection and reduces loss. The ability to detect fraud minimizes the loss of Disability Insurance funds to claims that should not be paid. Electronic filing is also providing the State with significant savings in postage costs, because not all forms need to be mailed to every claimant when they have an SDI Online account. The SDI Online ushers in a new era of enhanced customer service at the EDD, and is an innovative, technological advance toward a more efficient and paperless business environment.