Claims Management Solutions (CMS) Paper Claims to EDI

Reduce Healthcare Claims Processing Costs by Converting Paper Claims more Cost-Effectively

2009-08-12T12:03:55-05:00

Why and How to Choose a Vendor for Paper Claims Conversion (HCFA, UB, CMS & Dental)

Manually processing claims is extremely expensive and burdensome.In-fact it is estimated that claims processing inefficiencies add up to over 300 billion in healthcare costs. In today's economic environment organizations must be investing in appropriate business process improvement solutions that will reduce business expenditures; especially due to the fact that technologies exist today which allow organizations the ability to streamline processes, reduce operational costs, increase profit, and make better supported decisions with the help of built-in decision tools and analytics.

Vendor Selection - What Should You Look for in a Paper to EDI Vendor:

There are more than a few things an organization should consider when looking into using a Paper-to-EDI vendor; however, since we can't cover them all, we will cover a few. First, make sure that your vendor is interested in engaging your organization after you agree upon terms - i.e., pricing, turnaround time, quality, etc. Who wants to purchase from a vendor that becomes much less responsive to your needs after you sign? After all, entering into partnerships with a vendor does require both the buyer and seller to be committed to one another, sometimes for better or worse.

Another consideration that should be looked at closely is the solution itself. Don't just view some canned demo which can show the process when it works smoothly. Any good vendor providing a front-end claims processing solution for paper claims conversion (Paper to EDI) will be happy to allow your organization the ability to test drive the solution before making a decision as to whether or not it is the right solution for your organization. There is no one size fits all solution in the market today. Therefore, ask your potential vendor for a trial. Like mentioned in the previous paragraph, often times vendors oversell and under-perform, this makes a trial before you buy approach important.

Another consideration to look at in your vendor are the capabilities of the reporting and tracking tools built into the Paper-to-EDI solution. Data reporting and tracking tools are extremely important for supporting effective decisions that drive growth, efficiency, and profit at your organization. What about setting different users up with different screen data? A good solution will allow for certain users to have more control and reporting tools than others; not all users will need access to the same reports and tools.

Some additional considerations in choosing a Paper-to-EDI vendor include:

Will the returned EDI file feed directly into your adjudication system ?
Is there a web portal to access your information 24 * 7 ?
What security measures are in place to protect your data ?
What security measures are in place for patient record data ?
How is the organization backing data up - with whom and where ?
How long until the EDI file is returned from the Vendor ?
How robust is the solution ?

Incentives for Reducing Claims Processing Costs with a Paper-to-EDI Vendor?

A tremendous benefit in securing the "right" Paper-to-EDI vendor allows your organization the ability to create a lean organization with lean processes. Creating flexibility and agility within your organization will create stable operations which will ensure your organizations longevity. With a lean and nimble organization your business will have a new found ability to adapt to many environmental variables; often times variables outside of the control of the organization.

Some additional benefits in reducing claims processing cost with a Paper-to-EDI vendor include:

At-least a 70% increase in productivity
At-least a 50% reduction in administration costs
Increase in accuracy
Enhance the productivity of claims examiners
A more robust adjudication system will allow for more claims to be auto-adjudicated
No more time spent retrieving files
A digitized library of all claim forms and attachments
Better customer service!

The American Medical Associations Heal the Claims Process Campaign

2009-07-27T13:54:06-05:00

In July of 2009 data was released from the American Medical Association through their efforts to "Heal the Claims Process" - a campaign for eliminating waste within claims processing sponsored by the AMA. According to the AMA, claims processing accounts for 200 billion annually in added health care costs. I know, just amazing; amazing especially because solutions exist today which could easily cut this number dramatically. However, like I heard a friend once say, "you can't turn a battleship on a dime." This too is true of any systems process which has been in existence for a long period of time. Habits certainly begin to take over and change becomes more and more difficult to turn into action over time. After all, behaviors are reinforced through actions, and, actions are repeated. "A body in linear motion remains in motion with constant velocity until and unless an external force is applied on it" (Newton's laws of motion).

Within the claims processing world, the system has been gradually improving year-after-year. However, like the battleship, the system is not easily turned on a dime. Why is the process not becoming more efficient faster? For one, radical change is a slow process. People become accustomed to certain ways of performing tasks and continue to do things the same way until something causes a change - This is true most of the times anyway; there are always exceptions to every rule of course.

Data from my organization, Eagle Innovations, Inc. which has been providing health care solutions for business process improvement within the claims space for over 20 years, shows that at the least, a 30% decrease in costs is seen after the implementation of our recommended solution(s). There have been many organizations which have seen costs decrease much more than 30% but that all depends on the organizations current state and their leadership. Some organizations are much further along than others.

Over the course of the next few days I will be learning more about the details within the National Health Insurer Report Card and reporting my findings back through this blog.

Western Claims Conference: Conversations with Paper to EDI Prospects

2009-06-19T17:17:13-05:00

Hello World,

Recently I attendrd the Western Claims Conference. The WCC is "an educational forum where Life, Health and Disability claim professionals can:

Obtain tools and skills to meet the changing demands and requirements of the
various facets of the industry and the market place
Exchange ideas
Network which was both insightful and fun. Thank you to all of the organizers, attendees, presenters, and vendors, who were all so pleasant. The conference was great and I look forward to next year's conference" (Western Claims Conference Website)

While at the WCC I had the opportunity to have several conversations with users of Paper to EDI conversion services. I was also able to have discussions with organizations performing conversion in-house. Our discussions revolved around current processes and best practices for converting paper claims. Conversations also covered the struggles that each of their organizations and departments faced. One thing was very apparent, organizations who were considering outsourcing this function were a little hesitant but did realize the benefits.

I did also discover numerous organizations still using manual data entry processes in-house; I would have assumed a much higher shift toward OCR or outsourced services due to technology advancement, accuracy, and costs; after all, the costs of outsourcing this function can be very low and is a variable cost. Organization outsourcing will only pay for claims they are converting. Another benefit in outsourcing is found if the payer should lose a plan. With outsourcing the payer would not have to worry about tightening financial controls in a hurry; instead the organization would just stop sending, and paying for, those claims. Overall, outsourcing tremendously decreases costs, improves accuracy, and increases performance.

In today's business environment being competitive is critical - i.e., processing claims faster and more accurately; using less resources and producing more output. The principles of Lean Six Sigma teach us that it is not necessarily replacing people with machines, rather, putting people to better use - i.e., growing the business by obtaining more clients; providing better service to current accounts, overall increasing retention and satisfaction. Think about it! We could all wash our cars in the driveway and spend an hour doing it or pay $5.00 and drive it through a machine that could have it clean in under 3 minutes. I know that my time is worth more than that $5, and I am sure you feel the same way. My point is that organizations should not overlook the benefits technology has to offer.