Case Study #6Application DevelopmentSituationBTree consults for large dental practices that manage hundreds of dental claims every day. This is an enormous management challenge because the task of submitting and getting the claims paid has many facets. With thousands of insurance claims pending at any one time, the efficient processing of them is crucial to maintaining low Accounts Receivable especially when there is billing on the back end for any portion of a claim that is not paid. An example of what makes the efficient processing of insurance claims difficult at one health center in Connecticut is that the state computers incorrectly identifies which insurance patients have at the time of service. This results in electronic insurance claims being submitted to the incorrect insurance company or state program. The standard practice for managing electronic claims is to print reports out of the data information system detailing unpaid claims so they can be researched and fixed. Using these reports is time consuming, error prone and slow. They rely on accurate payment data existing in the system and sometimes a delay in the data entry of this billing information impedes the ability to get timely reports and to re-file e-claims efficiently. HindranceThere is no off-the-shelf health claim management software that could interface with thousands of different insurance companies to manage unpaid health claims. ActionsBTree is developing a solution aimed at managing the life cycle of a health claim. The system knows which insurance claims are outstanding, and with data received directly from the payors, knows which claims have been paid and which have not been paid. Within the software health claims are kept in one of several categories: not-yet-sent, sent-for-payment, rejected, and paid. We plan to expand the paid category to paid-and-accepted, and paid-but-underpaid to help our clients re-bill underpaid or incorrectly paid insurance claims. Claims are tracked by the date they were last handled. After thirty days, claims that still remain unpaid come back into the work bin to be checked on. Anytime a claim is rejected, or paid at zero, it is but back into the work bin to be checked on. This system is much better than printing reports because it presents a simple working interface to the user that is based on the age and status of the claim, so our clients can make sure to get them paid before they age out. ResultsClients have a much easier time managing there claims using a software tool that identifies which claims need attention rather than by trying to do this manually with massive data reports. Having a tickler system of sorts to keep prompting you about old claims before they “age-out” is critical to achieving a low Accounts Receivable and to running a smooth health business operation. |
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