Decision Desktop
The Challenge of Claims
Payers need
information tools to identify , track and fix claims issues in real time...
The healthcare claims process involves hundreds of steps,
systems, and people. Some of it is one paper and some is electronic.
It crosses organizations. It is both tightly regulated and poorly understood.
It it not characterized by easy and shared access to information. Few payers know or track
their top EDI submitter, top denial reason, or largest COB payer.
An Information Platform Designed for Claims
The Decision Desktop is a turnkey claims process reporting tool.
It was designed to support performance information
needs for staff across a payer organization - from provider
representatives to CFOs, from claims supervisors to account managers.
Payers use the Decision Desktop today to achieve the following:
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Track Provider Payment Issues.
Managing providers is perhaps the most significant
claims challenge payers face. The common payer/provider dynamic
is for the claims process issues to be 'payer driven'. Some claims issues
are payer driven. Few payers however, have the tools to manage individual providers
for key provider driven metrics such as EDI rate, duplicate claim rate, and eligibility denial
rate. The Decision Desktop makes it possible to manage providers
in a way they've never been managed.
-
Manage Compliance.
There is no reason to discover a compliance issue with a
big provider six months after teh contract has been set up. There are so many State, Federal,
Provider Contract, and Benefit related rules to follow that compliance can be a maze. The
Decision Desktop makes it easy to track compliance. Users can set alerts to track key compliance related
metrics such as individual denial reasons as well as turnaround time for providers, employers,
and lines of business.
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Reduce Administrative Cost.
Claims has made significant progress towards reducing administrative cost in the past
ten years. EDI rates have risen from 35% to over 65% and auto-adjudication rates are over
50% in most health plans. There are huge opportunities yet to tackle. Assum 5% of claims are duplicates,
another 10% are denied, and a further 5% are adjusted. The implication: 1 out of 5 claims is
processed at least twice. Healthcare claims is orders of magnitude away from anything approaching
six sigma.
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Manange Payment Risk.
How much was paid, denied and adjusted for the largest provider in your network last week?
How about out of network? How does that compare with the week before? The payment alerts in the Decision Desktop
allow payers to track weekly payment trends -- and find issues usually before the providers themselves find
them. The same applies to your employers, particularly those that are self funded. The Decision Desktop makes it
easy to manage their payouts and payment questions.
-
Improve service levels.
Claims is a service driven process.
Service metrics such as claims turnaround and claim denials are critical service
level drivers. The Decision Desktop enables you to track
Innovation, Flexibility, and Scalabilty
How does the Decision Desktop work? It works by combining three core data technologies.
First it loads open and closed claims data each day and applies a set
of business rules to each claim. This enables the Decision Desktop to
uniformly and transparently report performance (Would you like to see the rule used to determine duplicate
claim lines?).
Second, it aggregates the claim data to enable reporting across periods.
Decision Desktop aggregations make it possible to see monthly, quarterly, and
yearly views of data in seconds (Would you like to see the total volume of claims denied
in 2006 as a duplicate?).
Third, it loads the individual claim data into a search engine (claimfetch) that enables
users to search on indivual and sets of claims (Would you like to see 100 random claims
that were denied as duplicates for that provider?).
These three technologies enable robost reporting, alerting, and root cause analysis.