Case Study - Regional PPO

Client

This large, regional PPO (300 hospitals in 10 states) processes about 3.5 million claims per year. Approximately 60% of these claims were processed in paper form. The other 40% were submitted electronically.

Project

Claimshop^® was called on to analyze, simplify and automate the claims receipt and delivery, repricing and work flow processes.

Challenges to be Met

This company found themselves in a position where the slowness and inaccuracy of their claims repricing process had created a decidedly negative perception in the marketplace.

Their turnaround time was about 17 days.
They had an excess of manpower dedicated to working claims.
Their process was often inaccurate.
They had no capability for contract modeling.
No HIPAA-compliant outbound or inbound EDI had been established.
A large backlog of claims had developed.

Solutions Delivered by Claimshop

Claimshop analyzed the company's processes, determined where improvements could be made and delivered an appropriate set of solutions.

The solutions included

Inbound and outbound HIPAA-compliant EDI
Parallel test environments (so proposed contracts could be modeled and compared)
Automated group/payor and provider matching
"Stratification" (sub networking and tiering of items to be processed)
Interface with scanning vendor
Online, real-time repricing capability
Claims tracking and audit trail capabilities

Results

The results were dramatic. Turnaround time was slashed from 17 days to 24 hours (a reduction of 70%). Full-time employees dedicated to working claims were reduced from 42 to approximately 14.

In addition, this regional PPO

Implemented a paperless workflow (inbound paper was decreased to virtually zero)
Increased inbound EDI by 50%
Increased outbound EDI by 600%. This number continues to grow as Claimshop builds additional EDI connections to the Clients’ payor relations
Achieved HIPAA compliance
Improved Claims Repricing Accuracy to a virtual 100% level