Q4 2006: Quality Measures Survey

SURVEY COMPLETED AND CLOSED. The Quality Measures survey included two questions.

Question 1. Rank (1 to 5) the measures below in terms of which are most important to managing quality in a claims operation...

1. ___ Claims Adjustments
2. ___ Mispayments (overpayments)
3. ___ Calls per Member
4. ___ Call Talk Time
5. ___ Other

Question 2. Rank (1 to 5) the measures below in terms of which are most important to managing your claims operation...

1. ___ Claims inventory/backlog
2. ___ Claims turnaround time
3. ___ Examiner productivity
4. ___ Auto-adjudication rate
5. ___ Other

Quality Survey: Question 1 Results

Claims adjustments are a key measure of quality. .

Question 1. Rank (1 to 5) the measures below in terms of which are most important to managing quality in a claims operation...

Summary. Claims adjustments are a key measure of quality.

Our survey design for the quality question of the survey was not as well thought out as it should have been. Based on reply comments written on a number of the surveys, calls and quality should have been separate questions. Fortunately, there are some salvageable observations from the response data we have:

Claims adjustments are an important measure of quality. No surprise here. However, it is not common (in our experience) for plans to closely track (or understand) claims adjustments. Another key conclusion: we're still not clear about exactly how plans track and manage quality in their claims operations. A future survey will focus on quality. Most claims operations we’ve seen measure quality through back end audits of claim samples. These audit results are typically used to evaluate claims examiners/analysts and report to health plans.

On the call side, again, we should have known better. Mixing calls and quality muddied our results. Our question should have included call hold time and abandon rate. Needless to say, Call Talk Time and Calls per Member calls per member and call talk time were ranked last or second to last in terms of importance by 14 of the plans.

Survey replies were received from 26 health plans. The distribution of responses (shown right) is representative of the distribution of healthplans in the US.

Quality Survey: Question 2 Results

Turnaround time and backlog are the two most important measures used to manage a claims operation.

Question 2. Rank (1 to 5) the measures below in terms of which are most important to managing your claims operation...

Summary. Turnaround time and backlog are the two most important measures used to manage a claims operation.

Indeed, it is appropriate that claims operations consider turnaround and backlog to be their most important management measures. Claims operations are production environments. In a production environment the most pressing daily decisions tend to be focused around whether production is keeping up with the orders (claims). If production is falling behind (and backlog is growing) then managers need to make adjustments (probably to staffing).

The flip side of the importance of daily production measures such as turnaround time and backlog is the relative unimportance of auto- adjudication and examiner/analyst productivity. As management and production resources focus on backlog it is easy to underweight allocating resources to participate in longer-term process improvement efforts. However, the efficiency of a claims operation (what drives cost) is largely determined by process measures such as AA rate and examiner productivity. The key takeaway of this survey question is probably that the demands of production should not completely obscure the demand of process efficiency.

Twenty six healthplans responded to the survey. For a distribution by plan size, see question 1 above.