Transcript TransAct RePricer - Detail Presentation

Maryland Chapter
Monitoring Payer Performance
Mark Gagern
Aurora Healthcare
October 21, 2011
Goals
 Establish Key Performance Indicators to:
 Identify process issues.
 Recognize Denial trends.
 Monitor Patient Responsibility.
 Forecast Cash.
 Predict and Manage Administrative costs.
 Monitor contract compliance.
Identify Key Performance Indicators
 Select KPIs based on goals. What information will help
identify process issues, recognize denial trends,
quantify administrative effort etc?
 Identify sources. Where can the information needed be
found and how can it be measured?
 835/Remit Data.
 Transactions.
 A/R.
Identify Key Performance Indicators
 Determine indicators to use based on:
 Suitability. How well does the KPI measure a
specific process?
 Availability. Can the information be obtained from
current sources?
 Consistency. Is the information consistently
available?
 Automation. Can information be gathered without
undue manual effort?
KPI Suggestions
 First Pass Payment vs. Additional Follow-up
Required.
 Forecast percentage of claims which will pay
on initial billing.
 Identify what percentage of claims will need
additional action after billing.
 Sample:
Payer Group
1st Pass Paid
Follow-up
Required
MCO
72%
28%
Blues
75%
25%
Commercial
82%
27%
Medicare
93%
8%
Medicaid
90%
10%
82%
18%
KPI Suggestions
 Patient Responsibility.
 Identify the total patient responsibility to
measure against pos collections.
 Identify payers with increasing patient
responsibility.
 Sample:
Payer
PT Res % of
Charges
Cigna
8%
United Healthcare
8%
Aetna
6%
Great West
17%
KPI Suggestions
 Contractual Allowances.
 Verify appropriate discounts.
 Ensure out of state payments at HSCRC rates.
 Sample:
Payer
All Payers (Last 12 Months)
Contractual %
of Charges
7.25
KPI Suggestions Denials
 Denials.
 Monitor Denials in Key areas.
 Medical Necessity Denials.
 Sample: (last 3 months)
Payer
Denials as % of Charges
Aetna
1.24%
Amerigroup
.03%
Bravo
.39%
CIGNA
.96%
Coventry
1.2%
JHHP
.7%
United Healthcare
.04%
KPI Suggestions Denials
 Authorization / Pre-Cert Denials.
 Sample: (last 3 months)
Payer
Denials as % of Charges
Aetna
1%
Amerigroup
6
Bravo
7.6
CIGNA
1
Coventry
3.7
JHHP
.6
United Healthcare
2.8
KPI Suggestions Denials
 Place of Service Denials.
 Sample: (last 3 months)
Payer
Denials as % of Charges
Aetna
Amerigroup
.01%
Bravo
.11%
CIGNA
Coventry
.05%
JHHP
.02%
United Healthcare
KPI Suggestions Rejections
 Eligibility Rejections.
 Sample: (last 3 months)
Payer
Denials as % of Charges
Aetna
.86%
Amerigroup
1.7%
Bravo
.06%
CIGNA
1.5%
Coventry
1.5%
JHHP
2.4%
United Healthcare
1.4%
KPI Suggestions Other
 Additional Documentation Requests.
 Sample: (last 3 months)
Payer
Denials as % of Charges
Aetna
4%
Amerigroup
15%
Bravo
1.8%
CIGNA
.73%
Coventry
5.6%
JHHP
7%
United Healthcare
2%
KPI Suggestions Other
 Retraction Rate.
 Sample: (last 3 months)
Payer
Denials as % of Charges
Aetna
4.4%
Amerigroup
22%
Bravo
5.4%
CIGNA
6%
Coventry
4.5%
JHHP
5.9%
United Healthcare
2.8%
Sample Report Card
 ???Questions????
 Contact information:


Mark Gagern
[email protected]
Final
Lets eat Grandma
Lets eat, Grandma
Punctuation Saves Lives!