TransAct RePricer - Detail Presentation
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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!