Claims Processing

Less Pain, More Revenues

Summary
Claims processing is one of the most critical business processes within a medical practice. One large Orthopedic group in Houston had been struggling daily with a paper claims system that produced a large volume of unpaid claims and overstaffing in their Billing Office. The group was dealing with a paper load of more than 35,000 open claims and a staff of more than 30 people, who could not keep up with the volume.

Generally, the Billing Office worked accounts from paper reports, but this was not an efficient approach. The system itself was cumbersome and could take as long as four hours to run one report. When several staff members began running reports simultaneously, the system would overload. Another issue included paper reports, which were outdated quickly and inaccurately reflected claims status. A common problem was that a staff member could call about a claim that had already been paid.

Adding to the inefficiencies was the inability to track outcomes or establish a follow-up schedule. For example: if a biller called a payor on a particular claim one day, the group had no way of tracking the outcome or establishing when the next call needed to be made for that claim. They had to manually work through the piles of paper. Without a system, the group had no positive way to establish priorities, set-up a schedule for follow-up or track their financial results.

Finally, the group had no method for management to determine which staff members were effective at this process. There was guesswork as to who was ''good,'' but it could not be confirmed with the paper based system.

Observing this ongoing problem, Weston decided to approach management with a recommendation for a comprehensive, software-based solution. The group was eager to approach this problem from a new angle and gave the go-ahead for implementation.

Solution
Weston began by developing a custom software system to organize their workflow and increase efficiencies of the Billing Office.

We developed a system in three days to reduce the bureaucracy and inefficiencies of the paper system. We created and implemented a system called ClaimPoint! that separates claims and reorganizes them into queues. The basic philosophy is that every line item on a claim is assigned to a biller. Various billers can have responsibly for one or more line items on a claim. This allows various billers to work simultaneously on the claim. The responsibility can be categorized by combinations of physician, patient alpha or payor.

Management and staff can manage the work flow as there is a tracking component to allow anyone to review current status of a claim. Anyone can determine when the claim was filed, when it was checked, if there is an appeal, when the last time a person called, etc. The intelligence of the Billing Office is now shared and helps negate the issue of one person who is perceived as indispensable due to their claims knowledge.

Finally, all this information is logged and consolidated into statistics for management so they no longer have to guess who is ''good'' and who is not. The data is available objectively and gives management a professional and fair method of rewarding effective workers while assisting those who are struggling.

Benefit
The system was implemented in 2000 at a cost of under $30,000. Within a year, the group was able to process the same claims work with six fewer people, resulting in an estimated annual savings of $300,000 or $2.1 million through 2007.

Within 9 months, days in AR improved by 40%. As a result, the revenue stream was more consistent and physicians could focus on their practices more completely. An added bonus is that the group now sells the ClaimPoint! product to many other practice management systems where it has been successfully deployed.

Contact us for assistance in streamlining your claims processing.