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Data & Analytics

11:00 AM
Edward M. L. Peters, <a href=OpenConnect Systems" />
Edward M. L. Peters, OpenConnect Systems

Greater Healthcare Payer Efficiency Through Process Intelligence and Workforce Analytics

New regulatory mandates have placed extreme pressure on healthcare insurance payers to reduce administrative costs and operate more efficiently. Reducing costs in administrative roles is challenging because it is difficult to "see" in a digital workspace what the workforce is doing, how efficiently they are doing it, and whether there is a "better" way to accomplish the task. This challenge is compounded as workers traverse different applications, systems, and even user log-in IDs to accomplish their work. Conceptually, the keys to successfully reducing administrative costs are simple: improve the process to eliminate work, reduce errors and improve the productivity of remaining workers.

However, improving process requires visibility into the detailed effort and steps of how work is actually accomplished within current systems. This includes producing detailed metrics about the time for each activity as well as volumes and effort. In addition, you need to understand process variations (e.g., what is different about one set of processes versus another) and why they occur. Finally, you need to understand the actual productivity of your workforce: how much time they each and aggregately spend on an activity, transaction, or customer and why.

The good news is that healthcare insurance payers do have a solution; an approach that allows them to visualize and measure the work that is being performed in real time. Process intelligence and workforce analytics technology provides the ability to automatically capture and measure exactly what work is being done, how, and by whom.

In a claims center, an executive can see which claims pend by any attribute, including type, provider, or member. Such attributes might include work time (what actions were performed, how many times those actions were performed and at what rate of accuracy) as well as idle time (how much time is spent in what systems versus the amount of time spent outside work processes), making a comparison of high-productivity and low-productivity workers possible. Additionally, these events can be analyzed by any associated attributes such as pend by type and employee, work time by type, work time by provider, etc. This insight is not only available at the individual employee level, but can be expanded to look at performance and productivity on a departmental level, or even an entire business unit. The executive even has the ability to replay a particular employee's session -- viewing each step the staff member took in accomplishing a specific task -- making it possible to perform root cause analysis. From this understanding, the process could be automated to eliminate the work effort entirely, the plan could be modified to simplify handling of the issue, or agents could be trained in more efficiently handle the issue.

These scenarios are not conjecture, hypothesis or "futures." One of the largest U.S. healthcare insurance providers, delivering services to more than 35 million members, is executing on a process intelligence-based improvement plan today that saves more than $6 million annually. Utilizing process intelligence and workforce analytics software, the company significantly improved its auto-adjudication rate which realized lower administrative costs through:

- Fewer claims processors

- Fewer late processing penalty fees caused by regulatory violations

- Fewer claims adjustments

A major Midwest healthcare insurer also benefited from improved claims processing by applying this same technology. The effort involved multiple systems, local and national, as well as a dozen satellite claims processing sites. The software helped the company achieve $2.5 million in annual cost savings, increased the depth of its process analysis, and enabled both process improvement and auditing on a continuing basis.

Process intelligence and workforce analytics equips healthcare payer executives with insight into the true productivity and efficiency of their plan's work processes. More importantly, it allows them to understand the root cause "why" of process exceptions and failures. Leveraging this information allows healthcare payers to know exactly what is happening in their organization and what steps can be taken to maximize productivity, profitability and quality.

About the Author: Edward M. L. Peters is CEO of OpenConnect Systems, a provider of process intelligence and workforce analytics software. Mr. Peters is also the co-author of The Paid-for Option, which describes how healthcare reform could pay for itself by applying innovation, technology and evidence based management. Click here to e-mail the author.

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