Capturing Desktop Activity to Improve Healthcare Claims Processing

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Brian Spraetz's picture

Many healthcare insurance payers struggle with a manual claims processing system that is built upon a set of confusing, complex steps and time-consuming manual procedures. This often leads to delays and errors when processing claims, which in turn can lead to low MLR numbers or poor third-party quality ratings.

The reality is that the majority of avoidable healthcare claims errors are the result of manual mistakes. Fortunately, for healthcare payers this processor performance issue can be addressed and corrected. Deploying desktop activity capture technology in the claims operation, which tracks processor desktop actions, provides the necessary visibility into processor behaviors and activities to stop claims operational issues before they start.

A “typical” processing error workflow looks like this:

  1. Auto adjudication system “pends” claim for manual processing.
  2. Processor reviews claim edits.
  3. Processor finalizes the claim.
  4. Errors are identified by the provider.
  5. The claim is resubmitted for adjustment.

What is lacking is the ability to view the individual steps taken by processors when they incorrectly process a claim. Many claim processing organizations have processors that work from their homes, making it even more difficult to pinpoint what went awry when an error occurred.
With desktop activity capture and big data analytics technology, managers and auditors “see” what actions a specific processor took, eliminating the tedious and time-consuming process of sifting back through paper trails and reports to pinpoint the cause of errors. In addition to making it easier to identify the root cause of processing errors, organizations can enhance overall claims processing performance by:

  • Measuring performance (behaviors, value add metrics, etc.)
  • Identifying problem areas (claim types, time of day, etc.)
  • Drilling to actual claims/non-processing segments
  • Identifying areas for targeted processor coaching

This detailed level of insight gives companies an unprecedented “under the hood” look at their claims processing operation, and presents significant opportunities for health insurance payers to improve audit results, member and provider satisfaction, and reduce administrative costs.

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