The Challenge
Avoid financial penalties and improve performance with accurate data matching
As a long-time claims operations partner with our client, a major national health plan, Firstsource was well positioned to help identify and address costly inefficiencies. One of these was a lack of synchronization between our client’s system that manages provider data and the plan’s claims processing engine. Errors in matching provider data were causing claims to fall out and require manual intervention before adjudication. As many as 1 million claims annually were affected. The client asked us to improve coordination between the systems to ensure accurate data matching, reduce errors and improve first time match rate.
The Solution
Identify and prevent root causes of mismatches to improve auto adjudication
We analyzed the entire physician data-claims matching process, drawing on the expertise of the Firstsource manual fallout and operations teams as well as our client’s IT expertise. We identified specific logic failures in commercial claims matching and other disconnection points. In rectifying these, the Firstsource teams established enhanced process controls and a standardized workflow.
Now our teams receive a weekly spreadsheet of provider demographic data to validate. Through the process, Firstsource corrects the underlying issue, ensuring data is correct and synchronized across all relevant systems. This helps ensure future claims submitted by the provider in question adjudicate automatically, avoiding delays and associated penalties.
For example, team members will re-enter the provider ID and address sequence number in the claims systems for the requested incoming address and location code, which are already in the system. The re-entry will retrigger the system’s logic so it recognizes and routes the claim to the adjudication team, preventing a fallout.
Our teams also add the requested address, location code and segment within relevant applications to ensure the claims referencing this data are processed by the claims systems. We add payment information for the requested address and location code in the respective systems as well to ensure the back feed process is completed. This will confirm that all the systems are in sync to proceed so any claims that have fallen out can be reprocessed successfully.
The Results
Avoiding costs, improving speed and accuracy
The client estimates it is saving $1.5 million annually by avoiding interest costs and penalties as provider selection failures caused by discrepancies between the provider data system and claim engine are at an all-time low. The claims provider selection match rate increased to >99%, up from 98.7%—reflecting a 30% improvement. Provider Data Management match rates also rose, from 99.4% to 99.7%, demonstrating even greater data accuracy.The claims provider selection match rate has improved to 99% from 98.7%, a 30 percent increase. The Provider Data Management match rate increased from 99.4% to 99.7%.
As claims auto-adjudication has increased with improved data matching, Firstsource teams have capacity to review more data match failures, increasing reviews from an average of 2% to an average of 93%. That more than 4500% increase in reviews has enabled Firstsource to identify and remediate additional claims leakage.