Healthcare
Important information contained in patient medical records, patient billing records and medical insurance claims can be captured and compiled into an integrated electronic patient file using document automation technologies. Confidential records can be protected from unauthorized access. Staff and physicians in different locations can review patient records at the same time from a PC connected to a network or the Internet. Claims processing can be streamlined, and secure backup of all information is provided in case of disaster. Documents are never lost, never misfiled and never out of file.
Company: a $2.1 billion health plan operating in the northeast with a network of about 19,000 physicians and other health care professionals. It has consistently been named one of the nation's top-ranked health plans for quality and member satisfaction.
Dilemma: Reported annual losses of $227.4 million and realized the need for dramatic change throughout the organization. Although this included initiatives at all levels, one initiative was to reduce total claim processing costs. The baseline for change was as follows:
- 15,000 claims processed daily with an estimated internal cost to process of approximately $900,000 per month (including capture and adjudication).
- In-house processing unit cost was estimated at $1 to $1.50 to capture the data.
- Adjudication Costs were estimated between $3 and $5 per claim (for those claims that did not auto-adjudicate).
- 60% of claims did not auto-adjudicate.
Solution: They identify a strategic partner who is a specialist in claims processing, develop attainable goals, and begin a collaborative effort. The mutually-agreed upon goals were:
- Reduce Capture Costs from $1 to $.35 per claim
- Improve Auto-Adjudication Rates from 40% to 60%.
Outcome: The relationship was able to meet, and exceed, goals while creating a long-term, mutually beneficial collaboration to improve the Value Chain. Specifically:
- Keying costs initially reduced to $.37 per claim (continued improvements to the process have yielded additional gains — cost today is at $.28 per claim — including imaging).
- Auto-Adjudication rates improved initially to 80% and are today at around 98%.
- Introduced Imaging System to improve In-house adjudication efficiencies (unexpected benefit).
- Costs to process and adjudicate claims are now estimated at around $135,000, a net savings of over $750,000 per month!
Today: The company is proud to announce that through a company-wide initiative they have been able to record the desired turnaround. The CEO of the company stated:
Find out How MetaSource Can Help You"We have generated, in just two years, a $254 million improvement in our financial results, while at the same time significantly improving our operating performance . . . We're getting a great response to our administrative simplification agenda . . ."