Processing claims quickly and accurately is one of the biggest challenges payers face today in healthcare industry. Huge volume of claims notwithstanding, multiple and incompatible systems requiring significant manual hand offs have made the timely disposal of claims the single biggest burden on operating costs of payers. Add to it the problem of incorrectly filed claims that payers need to handle, leading to choking of band-width on account of re-processing; the problem suddenly becomes even more acute. With state specific regulations penalizing such delays, it has become a matter of survival for payers to figure out the optimal trade-off between analysis one claim warrants versus time it takes to get it through the system.
Solving this challenge is not a straightforward thing. The presence of dis-integrated data, multiple rules engines and several hand-offs in the processes creates significant challenges in processing the claims quickly. It is thus critical to adopt a systematic approach in addressing the challenge. To begin with, one needs to have a thorough understanding of various inter-linkages of a claims processing life-cycle. The graphic below highlights the life-cycle of a claim:
Once the process and data flows have been understood, the ‘onion needs to be peeled’ in a structured manner to ‘reduce the dimensionality of the problem. In our experience, frameworks and tools come in very handy to achieve ‘localization’ of the problem. At Axtria we have developed a proprietary framework ClaimIQ which assesses the claim on three dimensions: state (given regulatory hurdles), claim type (IPD, OPD, Lab Visit etc.) and particular process step of processing lifecycle. The diagram below highlights the construct of ClaimIQ framework:
Once the problem has been localized on these three dimensions, appropriate rectifying mechanisms are identified through either a process re-engineering initiative, technology automation project or an organizational alignment program.
At Axtria, we strongly believe optimizing claim processing time is not something that can be done in an ad-hoc manner. In our experience, companies tend to jump to solutions too often too soon. We believe first of all, it needs a clear commitment from executive management since addressing it comprehensively is probably a two to three year journey. Then, given the multiple dimensions and processes (and systems) involved – it needs a rigorous structured framework to remove the noise and localize the problem to select meaningful dimensions. Once the ‘localization has been achieved, it is to be addressed through either a process re-engineering initiative, technology automation project or an organizational alignment program. We truly believe frameworks and tools like ClaimIQ are a must-have if you are to embark on this journey.
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Amanjeet Saluja, Principal with Axtria, is an experienced leader in Healthcare Analytics. He has provided extensive consulting solutions to multiple healthcare clients across areas of underwriting, operations and claims processing
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