Generating Cleaner Healthcare Claims

Claims Processing : Ensuring Cleaner Claims Dr Kunalsen Sawant

Agenda ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

What is a Clean Claim? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Why Clean Claim? That’s in an ideal world…….

Providers Payers ,[object Object],[object Object],[object Object],[object Object],[object Object],Why is claims handling still difficult?

How big is the problem? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Higher %age of claims getting processed faster by making claims ‘Clean’ Source: America’s Health Insurance Plans (AHIP)

What is the key issue? Healthcare is the only industry where the seller (provider), at the time of service delivery, may not know how much services a buyer (patient) would consume totally, what would be the payor obligation to reimburse, how much should they collect from the patient and by when…………… Providers must manage a disjointed and protracted receivables path, as a result they are actively seeking systems which integrate diverse data sources to present an aggregate view-point in managing claims and receivables…………… ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],Admission Care Delivery Charge Capture Claim Submission Pre-admission ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Claims Lifecycle overview Claims Lifecycle

Industry Best practices for Cleaner Claims Financial Health Information management Ensure that your processes mandate….. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Daily Weekly Monthly Best practices for Claims handling Ensure that you track….. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Newer initiatives- CAQH guidelines ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Give Providers Access to Information Before or at the Time of Service...

Reasons for Pended/Delayed Claims Source: AHIP

How quickly Providers submit Claims? Source: AHIP Source: AHIP

Claims Statistics Source: Humana

Generating Cleaner Healthcare Claims

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