By Samir Panchal, Advisor, Freed Associates
Unbiased doctor associations, administration service organizations, PPOs and well being programs all compete for a similar suppliers. Typically the aggressive means of 1 group over one other to draw and retain suppliers comes all the way down to that group’s means to ship each high-quality providers AND positively affect suppliers’ money move.
A outstanding regional payer sought to increase its claims administration providers for suppliers. Nonetheless its growth was hampered resulting from a number of income cycle points. Elevated fee turnaround instances, getting old accounts receivable (AR) and excessive denials led a number of taking part suppliers to specific considerations in regards to the payer’s service. Some suppliers even threatened to alter their claims administration assist. In response, the payer’s management launched an instantaneous and complete effort to establish and proper these income cycle dealing with points.
Missing adequate inside sources to handle its claims and income cycle challenges, the payer engaged an exterior consultancy to optimize claims workflows, shut out getting old accounts and implement automated posting of well being plan fee denials. This consultancy was chosen primarily based on its important prior operational and income cycle experience and a promise to rapidly obtain constructive outcomes.
Reaching a Collection of “Fast Wins”
The payer and consultants started by planning to attain a number of, particular fast “wins,” primarily based on analyzing and bettering the corporate’s AR processes and getting old. The objective was to establish the foundation causes of the AR points, devise methods to scale back or resolve these points, and subsequently spotlight to suppliers the payer’s fast enhancements in claims administration.
The consultancy’s evaluation rapidly revealed a disconnect between the payer’s claims and IT groups, prompting collaborative enhancements between these two groups to boost the turnaround time of AR postings. A number of course of and expertise points had been recognized. The consultancy escalated the decision of a number of operational bottlenecks that weren’t receiving adequate consideration and assist. For instance, the payer was experiencing a backlog of claims resulting from pending medical correspondence in search of further enter earlier than these claims might be processed.
Based mostly on a backlog of supplier service inquiries to the payer about denials and associated fee delays, the consultancy analyzed denials and their root causes, and advisable claims dealing with enhancements.
Along with addressing the payer’s fast AR wants, the consultancy additionally recognized a number of methods for the group to optimize future operations. For instance, this work included reviewing claims group member capabilities and workloads, figuring out operational challenges with the group’s present staffing mannequin and recommending actions to handle staffing and workflow deficiencies. Specific consideration was paid to the correlation between staffing numbers, work quantity, and particular payer turnaround time.
By claims perform staffing and workload, it was potential to establish alternatives for bettering denials administration and supplier efficiency and fee contract variance reporting. It additionally grew to become obvious how the payer may enhance present supplier relationships by rising value-added providers, comparable to instructional choices on denial administration and income administration.
Quick Outcomes, Lengthy-Time period Beneficial properties
Based mostly on the consultancy’s evaluation of the payer’s claims administration and the implementation of a number of suggestions for enchancment, the payer considerably lowered its quantity of open AR and lowered its claims workflow turnaround instances. Because of this, the payer considerably improved each its reimbursement assortment and supply to taking part suppliers.
By way of this work and a collection of corresponding program enhancements, the payer finally achieved a $2+ million annual improve in income for its supplier claims administration program, and document month-to-month claims volumes. These enhancements not solely meant a big monetary acquire for the payer, but additionally preserved the payer’s skilled popularity and the long-term enterprise potential of its supplier claims administration program.