Contributor: Don Canning
When speaking with Healthcare Payer’s Chief Operating Officers on a recent customer listening tour, we learned that many achieve industry benchmark standards roughly between 70-80% for claims auto-adjudication. Conversely, when evaluating overall satisfaction by large employers, they experience a decreased benchmark by an average of five percentage points, from 64% in 2008 to 59% in 20091.
Perhaps the reason for the discrepancies is lack of operational efficiency and to the degree claims auto -adjudication is completed hands-free. Some interesting assessment patterns indicate that actual auto-adjudication rates are more likely in the 60% to 70% range. Breakdowns in auto-adjudication processing combined with varying data quality are key culprits causing payers to perform:
- Manual workarounds that cause inefficiencies
- Poor data quality slows claim processing
- Difficulties performing fraud pattern analysis
This causes payers to have a series of manual patch-quilt processes catching claims that fall out of the automated process, ultimately driving costs skyward and slowing down response-time to employers and members.
What’s keeping many COO’s awake at night is their inability to control rising costs, maintaining tight claims management controls and staying competitive – all while raising quality of services and employer’s service satisfaction ratings. Other c-levels executives are looking towards COO’s to provide upward scalability demanding high-performance operations that can double or triple membership roles to meet aggressive growth plans that may include mergers and acquisitions.
For more information about how to improve auto-adjudication benchmarks and data quality preparation read: http://sungard.com/~/media/FinancialSystems/Brochures/Insurance/iWorks_brochure_formworks_august2011.ashx