Implementing medical claims software represents a big investment with the potential for even bigger rewards. You are probably excited to get it up and running as quickly as possible – but implementing new software comes with real risks.
The medical claims process works much like any other type of claim, involving people, facts, systems, and vendors. Compared to other types, however, medical claims can include more touchpoints and steps as it moves toward resolution. That complexity can lead to unnecessary procedures that can threaten your productivity and financial ratios – and hurt your claimant experience. The last thing you want is to carry over inefficiencies that plague your current situation into your new software.
The key to a smooth medical claims software implementation starts with an objective analysis of your current process to identify what is needed and what is not. Here are three steps to help cure your inefficiencies so you can get the most out of your software.
Step 1: Understand your medical claims process – before you make changes.
As the saying goes, learn from the past, or you’re doomed to make the same mistakes again. In that spirit, start by mapping out how your company currently processes medical claims. Whichever of the many mapping methodologies you choose, you may soon find yourself immersed in flowcharts, swim lanes, and process narratives. The way you document your medical claims process, however, isn’t as important as how you approach the exercise.
When you set out to map how your adjusters currently process medical claims, be sure to scrutinize each step, including how they:
- Report losses
- File electronic claims
- Manage claims data
- Case-manage claims
- Process and retain documentation
- Set, adjust, and monitor reserves
- Process payments
- Report claims data
- Ensure regulatory compliance
- Integrate with third-party providers
- Fulfill reinsurance reporting needs
- Manage policies
- Integrate with other data sources
Once you’ve completed this exercise, you can begin to diagnose the strengths and weaknesses in how your claims are processed. Those insights then will help you determine what will be carried forward and what will be left behind.
Step 2: Don’t perpetuate bad legacy processes.
Just because something has always been done a certain way doesn’t mean that’s necessarily the best way to do it. Automating a bad process in a new system simply helps you do the wrong thing faster. Implementing new medical claims software solution grants you an opportunity to critically assess the way your organization processes claims and make changes where warranted.
Here are some questions to help you identify potential red flags:
- Do your current solutions talk to each other?
- Where are the bottlenecks in your claims process?
- Which steps take the longest to complete?
- Where do employees complain the most about the work or the effort required?
The answers to these questions will help you identify the root cause of delays and extra costs currently hiding in your medical claims process. You then can structure your new system to eliminate those weaknesses and inefficient use of resources.
In the end, any claims management software is only as good as the processes it supports – so make sure your processes are sound before you commit to a new software solution.
Step 3: Embrace the power of data analytics.
Data analytics—especially in a data-intensive area like medical claims—can deliver real insights into your current processes that you otherwise might have missed. When you mine data for important information about how you process claims, you can discover powerful knowledge about your claims process, and the drivers behind metrics like:
- Duration/time to settle
- Fraud detection rate
- Claims in litigation
- Closure rate
- Loss ratio/expense ratio
By mining the data behind these metrics, you may be able to discover where you need extra help, where you need supervisory attention to assess and manage work levels, and where you need to invest in additional expertise. Analytics also may help you determine ways to more efficiently route claims so that simpler claims go to lesser experienced claims handlers while complex claims go to more experienced personnel.
Your Chance to Fix What’s Broken
New medical claims software can add all the efficiencies and improvements you need – but only if you first do a thorough check-up of your current processes. The result will make your adjustors happier, your customers happier – and you also might save some money.