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Increase
electronic claims
Process
more claims with the same resources
Lower
administrative costs
Reduce
IT costs
Increase
first pass rate
Reduce
835 (Payment) reconciliation expenses
Lower
cost of processing non-compliant claims
Reduce
future EDI errors
Challenge:
increase electronic claims
The Vice President of Information Services for a large health plan
found that forty percent of her incoming claims were still on paper
almost 3 years after adopting HIPAA; these cost an average of $20
per claim to process versus 40 cents per claim for electronic claims.
The main obstacle to electronic claims was the time and expense
of connecting and testing providers' IT systems with the payer's
systems.
Solution
Providers go on-line, connect, test, and begin sending electronic
claims. The providers receive detailed feedback instantly that permits
them to debug their electronic submissions without any human intervention
required by the health plan.
Result
An increase in electronic claims and greatly reduced claims processing
costs and greatly reduced claims processing costs.
Challenge: more claims with the same resources
The Director of Operations was focused on achieving the lowest cost
of operations in the industry. A single data center supported an increasing
number of plans and claim volume. The data center had to process more
and more transactions with the same, or fewer, people.
Solution
By using better automation, he was able to improve productivity across
the board. Areas of optimization included automated pre-adjudication
filtering of claims, outsourcing the maintenance of standards and
edits, on-line correction of errors, management reporting using a
business intelligence dashboard.
Result
Reduced processing costs, improved profit margin, lowered customer
service costs and reduced future claims errors.
Challenge: To reduce future EDI errors
The Director-Information Services of a large healthcare payer was
concerned about the cost of failed claims. Correcting and processing
a failed claim cost about $28 versus $2.50 for a claim that passed
the first time. He wanted to attack this expense at its source by
reducing the number of systemic noncompliant claims.
Solution
He uses a dashboard to identify the most common claim errors and
their sources and use the information to work with providers to
reduce incoming claims errors.
Result
Lower costs and better provider relations.
Challenge:
To lower administrative costs
The Vice President of Information Services for a large health plan
wanted to reduce her two largest costs: clearinghouse fees and call
center expenses. Clearinghouse fees were increasing. Call centers
were spending an average of $284 to correct a claim.
Solution
Her Providers are now directed to a self-service Internet portal that
automates signing up, testing, and connecting providers for direct
EDI. They also use easy, on-line provider-driven claims corrections
and immediate resubmission that lowers the cost of resolving an invalid
claim to about $.25.
Result
Reduced clearinghouse fees, lower customer service expense, and a
better support experience for providers.
Challenge:
reduce IT costs
The CIO for a health care payer wanted to reduce the cost of transaction
processing. He was using the validation module of his EDI translation
engine; it was slow in execution, required coding to maintain or
change, and had limited capabilities. He wanted to increase the
speed of claims processing, reduce the time and effort needed to
make changes, and introduce business rules and claim-level rejection.
Solution
He has cut his claims backlog, decreased maintenance costs, and
improved validation and claims processing by using trading partner
specific rules for content and form. This has stopped the rejection
of entire batches for the sake of a single non-compliant claim.
Result
Lower IT costs overall, and improved provider relations.
Challenge:
increase first pass rate
A Vice President in charge of claims found that correcting a failed
claim cost about $28 versus a cost of $2.50 a claim for a claim
that passed the first time. He wanted to increase first pass rates
by reducing errors in incoming claims; improving validation against
HIPAA and other standards; and splitting bad claims from a batch
rather than failing the entire batch.
Solution
By adopting real time validation technology, his EDI staff can now
identify common errors and their sources, provide deep validation
for HIPAA and other standards along with partner-specific edits,
and return failed claims for corrections while re-balancing and
re-sending the remaining transactions.
Result
Increase in first pass rates and correspondingly lower administrative
costs.
Challenge:
To reduce 835 (Payment) reconciliation expenses
A Vice President in charge of electronic payments for a health plan
wanted to lower the expense of reconciling and correcting his 835
remittance payment advice messages. Claim data was used to create
835 Health Care Claim Payment Advice messages by a translation engine;
at the same time, a payment was issued to the provider based on
the summary of these claims. Sometimes, the sum of the claims in
this 835 did not match the payment, or the 835 itself wasn’t
HIPAA-compliant. This fouled a provider’s accounting system,
increased their administrative costs, and decreased their satisfaction
with the payer. He wanted to ensure that the outgoing 835 matched
the payment and was compliant before issuing the 835.
Solution
TI Payment Manager was deployed to permit the health plan to easily
find and view 835s to check them against payments and write business
rules that ensure internal consistency. Automatic alerts now inform
them if 835s are ill-formed 835s and they are instantly returned
to a web portal for correction and resubmission.
Result
Internal and external consistency, an annual reduction of $720,000
in processing costs, and improved provider satisfaction.
Challenge:
To lower cost of processing non-compliant claims
The V.P. of Electronic Claims Processing wanted to reduce the cost
of correcting and resubmitting claims that had failed validation.
He staffed a 100-person call center who responded to provider queries
to manually resolve claim errors; this was expensive and took too
much time. He sought to automate provider notification and correction.
Solution
He invested in TI InStream which automatically alerts his providers
of bad claims submissions and permits providers to self-correct
without requiring intervention by call center personnel.
Result
Lower call center costs, faster resubmission, less expensive remediation
of claims, and improved provider relations.
Challenge: To reduce future EDI errors
The Director-Information Services of a healthcare payer was concerned
about the cost of failed 837 claim. At $20 and higher, the cost
of correcting and processing a failed claim is over 10 times that
of a claim that passes the first time. He wanted to attack this
expense at its source by eliminating the most common causes of noncompliant
claims...
Solution
By using TI Claims Manager to enable the capture and ad hoc reporting
of transaction errors, he gained access to up-to-the-minute dashboards
showing transaction processing patterns and trends. This advanced
management reporting permits him to identify the most common claim
errors and their sources and to use the information to work with
providers to reduce incoming claims errors.
Result
By eliminating the most common types of errors, he lowered costs
and improved provider relations.
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About HIPAA
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