Mitigating Cost and Abrasion with Electronic Claims Submission

Introduction

One of the largest health insurance plans in the South and Availity, the nation’s largest real-time health information network, recently collaborated to eliminate the submission of paper claims by the health plan’s provider network.

To accomplish this goal, the health plan decided to:

Leverage technology that simplifies the exchange of administrative, clinical and financial data.
Implement provider education and change management processes to support providers making the transition from paper-based claims to easy-to-adopt electronic workflows.
Identify key performance indicators to measure success, implement further process refinements as needed and gauge return on investment.

Challenge

The health plan, along with many members of its provider networks, faced substantial challenges with paper claims. In addition to inefficient manual processes, these claims often resulted in rejection rates up to 73% per month, delayed or lost claims, provider abrasion and increased demand for customer service support. In addition, some clearinghouses used by providers were surreptitiously dropping claims to paper, and many providers were reluctant to submit claims electronically.

Solutions

The health plan used a combination of technology, change-management strategies, and provider education to resolve this issue. The implementation date of March 1, 2024, was strategically chosen to avoid the busy open enrollment period and provide additional time to communicate with providers.

Technology: The health plan leveraged Availity Essentials™, which delivers streamlined claims submission as part of a robust claims-management workflow. Availity Essentials™ features an intuitive interface that supports multiple workflows, simplifying the exchange of administrative, clinical and financial data. This solution leveraged innovative editing and transaction capabilities to ensure smooth and efficient claims processing.
Change management: The health plan created a dedicated project team, representing various departments within the company. This team was responsible for monitoring data consistently to identify areas of concern, create and monitor the paper claim exception/waiver review process and work with Availity teams to facilitate provider outreach and education.
Provider education: A comprehensive communication strategy was essential for the project’s success. This included provider newsletters, medical society meetings and targeted letters. Additionally, live training sessions and help documents, such as guides on submitting corrected claims, were provided to ensure providers were well-prepared for the transition. Availity assisted with outreach to trading partners/clearinghouses.

Results

Metrics: The implementation of Availity Essentials for providers submitting paper claims yielded impressive results. There was a significant reduction in denied and/or lost claims, a decrease in customer service calls, and shorter processing times, which reduced from being up to a week behind to within one to two days. The first-pass rates for electronic claims also saw substantial improvement.
Cost-savings: The cost-savings achieved were considerable. By eliminating paper claims, the health plan saved $1.58 per claim. Given that the health plan previously received 23,500 paper claims monthly, this translated to a monthly saving of $37,000. Additionally, the termination of agreements with external vendors resulted in further savings of thousands of dollars monthly.
Provider feedback: Provider feedback was overwhelmingly positive. Satisfaction surveys and quality assurance on phone calls indicated reduced frustration and improved understanding of electronic submissions. Providers appreciated the streamlined process and reported fewer issues with claims submission. Additionally, providers who were initially resistant to change, through education, have successfully made the transition to become fully electronic.

Next steps

The health plan plans to build on the success of this project by exploring additional areas for provider engagement and technology integration. Upcoming initiatives aim to further enhance the efficiency and effectiveness of claims processing.

The transition to electronic claims submission has been a resounding success for the health plan. The benefits of this change are clear: reduced costs, improved provider satisfaction and streamlined operations. This case study serves as a valuable example for other health plans looking to implement similar solutions.

Lessons learned

Leverage technology that simplifies the exchange of administrative, clinical and financial data. Provide thorough training and support to ensure providers are comfortable with the new system.
Develop a comprehensive communication strategy to keep providers informed and engaged. Establish a dedicated project team with representation from all relevant departments.
Identify key performance indicators to measure success, implement further process refinements as needed and gauge return on investment. Monitor data consistently to identify and address any issues promptly.
Ongoing provider outreach and education is critical post-launch.

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Mitigating Cost and Abrasion with Electronic Claims Submission

Introduction

Challenge

Solutions

Results

Next steps

Lessons learned

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