In This Issue: Quality and Decision Support Compliance

Issue summary and other notes...

Article 1 Quality in Claims. There is more to 'quality' than payment accuracy.

Article 2 Data Warehouses and HIPAA compliance. Best practices for manage HIPAA compliance and reporting environments.

CH Tip Finding good reps. Demand for good customer service reps is high.

Notes

"How did you go bankrupt?" a Hemingway character is asked in The Sun Also Rises. "Two ways," comes the answer. "Gradually and then suddenly."

Everybody wants to rule the world. Tears for Fears

“You kind of wonder how I lost the tournament. I didn’t make that many mistakes. It’s not like I choked. When you shoot thirty-one in nine holes of golf like Tiger did, you’re going to catch a few people.” Matt Goggle on his final round loss to Tiger Woods at the Pebble Beach National Pro-Am

“What worries me is the possibility that we’ll create a world that is much more economically efficient – but that is much less satisfying to live in… Tom Malone MIT professor

Quality in a Claims -- A Different Perspective

We all know about accuracy and how to measure it, but few have thought more broadly about quality in claims...

It is easy to poke fun at all of the books, gurus, certifications (ISO 9000?) and buzzwords (zero defects!) that have emerged around quality. As faddish as quality might seem, surveys typically show it plays a significant role in product and service purchasing decisions. Its also not uncommon for companies to underestimate it’s importance (witness the auto industry in the United States). Finally, a significant portion of the process change efforts companies undertake are focused on improving one or more dimensions of quality.

Claims operations are all over the map in terms of how they measure and manage quality. A very common definition and measurement is claims accuracy. Claims accuracy is indeed a key measure of quality. However, there is more to quality than claims accuracy.

Improving quality in a claims operation starts with a definition. Three quick rules about defining quality: First, it should be defined as an actionable measurement. Many claims operations define quality measures as rates (99.95% claims accuracy). Rates are helpful to manage trends over time but from an operational standpoint it is usually easier to work with counts or dollar amounts. Something like – Claims Team Y is shooting for fewer than five errors this month. Second, quality should be defined in a customer-focused frame – quality is a means to improve the service experience of members. Third, it helps if the definition can be tied to bottom line results.

How to apply the guidelines to the hundreds of steps/activities in a claims process? The most manageable way is to organize the many steps into a set of sub-processes. For each sub-process, use the three guidelines (actionable, customer-focused, and bottom line impact) to develop a set of quality measures. A preliminary set of sub-processes, with recommended measures is outlined in the box to the right.

Here’s our set of six sub-processes and with quality measures for each:

1. Member enrollment process: Number enrolled after effective date, member card accuracy.
2. Plan installation process: Number loaded after effective date, number of plan related financial errors.
3. Provider contract process: Number loaded after effective date, number of contract related financial errors.
4. Input / data capture: Number of financial input errors, average days to input.
5. Claims: Number of financial processing error, Average turnaround time.
6. Member / Provider inquiry process: Number answered in more than 30 seconds.

HIPAA Compliance for a Claims Data Warehouse

How do the HIPAA rules apply to your data warehouse?

Does HIPAA matter with respect to your data warehouse? We all know HIPAA, and most of us fear it a lot less than we did three years ago. That said, Data Method, the publisher of the this newsletter develops reporting solutions for claims operations. Here’s the compliance checklist we’ve developed to support our decision support solution.

In order to simplify your HIPAA efforts we’re going to divide claims operations into two parts (and for the purpose of this article, we’re interested in the second):

1. Transaction processes and data: The activities and systems used to process a claim.
2. Decision Support processes and data. The tracking and reporting activities and systems used to manage the claims process.

At its simplest, HIPAA is about one thing – members regard their medical information as something that belongs to them, not to their health plan. This nets down to two related issues – who (security) can access what (privacy). Security and privacy are challenging issues in the world of decision support. Below are three steps to help address them both and begin moving your organization towards HIPAA compliance.

1. Structure reporting needs. Security is difficult to manage in an unstructured environment. Chunk up the claims process (input, contract, eligibility,…) and define a set of information needs and an decision audience for each chunk. Once needs and audiences have been defined, security is a more manageable task. On the privacy side, very few claims process reporting needs require member information – so remove it.
2. Develop flexible decision support infrastructure. In any business, eighty percent of reporting needs are met by existing reports and applications. Without a responsive process to handle the remaining ad hoc needs, managers will find a way (albeit a non-compliant way) to get the information they need. How many desktop access databases are there in your department? Perhaps, the largest business challenge HIPAA presents to health plan IT organizations is to be vigilant about security while at the same time supporting claims managers with access to needed information.
3. Manage the reporting cycle. Security is more than managing end user access. In a typical reporting cycle information is output from a transaction system, loaded into one or more databases, and output in some type of report format. Lots of things happen to the data as it moves from mainframe to server to desktop. Compliance will likely require procedures to manage who can access the data at each step.

A few additional HIPAA resources and links which might help. HIPAA compliance will require time and resources. Plan for it. Allocate resources. Consulting dollars are typically driven by the failure to plan or execute not the pure lack of knowledge.

CH Tip: Finding Good Reps

Reps are hard to find. Here's why...

Based on 186 managers who participated in a survey of 771 US call centers, the average hourly wage of top-paid full-time agents ranged from $6.90 to $40 (median $15). The five most competitive industries for top-paid agents' hourly wages who paid $15 and up were Computers (91%), Manufacturing (86%), Healthcare (63%), Insurance (62%), and Telecommunications (62%). The obvious conclusion: Reps whose jobs require domain knowledge mastery (i.e. benefit plans or computer hardware) get paid more. These statistics were reprinted from a survey by Incoming Calls Management Institute (6/2004) on the Call Center Network Group website (www.ccng.com)