The Effect of Claims Processing Work Simplification Initiatives on Network Non-Institutional Professional Claims Processing Time
Abstract
Managed care organizations (MCO) must make every effort to improve the effectiveness of claims processing and reporting or they will risk the loss of member and provider satisfaction and ultimately lose their ability to remain solvent. The status of claims administration has been elevated in light of the fact that somewhere between 73 and 93 percent of all premium dollars are paid out for medical care in capitation and claims payments. An effective MCO will use claims processing data to manage the cost of health care on a case basis and in aggregate. Designing appropriate claims reports is essential to a well-managed healthcare organization s ability to effectively forecast liability trends and institute corrective steps. When TRICARE Managed Care Support Contracts were brought on-line there was no longer a direct contractual relationship between the FI and the government. Consequently, the Departmentof Defense was no longer at risk for either the expenditure of healthcare dollars or the adjudication of claims. Unfortunately, TMA continued to monitor the MCSC as if the government maintained the risk and was overly prescriptive with literally thousands of edits that slowed the claim process down. TRICARE has had claims processing timeliness and accuracy issues since its inception due in large part to the numerous eligibility categories, differing cost shares and benefits, the three health plan options (Prime, Extra, and Standard), and its reliance on data exchanges. TRICARE Management Activity (TMA) recognized that failure to respond immediately to beneficiary and provider concerns regarding claims processing would result in the loss of both patients and network providers. TMA tightened the timeliness standard of 75 percent of claims processed within 21 days to 95 percent of clean claims within 30 days and 100 percent in 60 days. This case study was conducte
Document Details
- Document Type
- Technical Report
- Publication Date
- Apr 13, 2000
- Accession Number
- ADA420982
Entities
People
- Barbara A. Coleman
Organizations
- Academy of Health Sciences