A leading ACO (Accountable Care Organization) and medical group manager faced significant challenges with its claims adjudication processes due to poorly designed auto-adjudication rules. These rules caused continuous claim cycles, creating ongoing issues. Their wide range of operations across rural areas, multiple service organizations (MSOs), and specialized environments, further complicating the situation.
Facing the Adjudication Challenges
HCIM traced the root cause back to poorly designed auto-adjudication rules. Timely Filing was one of the settings that were configured, and a rule was created for. There was a rule to auto deny the claims that were submitted untimely. However, there are special provider contracts that have a custom number of days to submit claims, not the standard settings from the Timely Filing configuration. These claims were being adjudicated incorrectly, being paid or denied incorrectly.
SymKey's Transformative Role in Claims Processing
Understanding the unique needs and complexities of the organization, HCIM proposed a dual-pronged solution. First, by establishing a specialized query that acknowledges both standard and unique provider agreements. Second, by setting up a reference table that aligns with specific submission deadlines. This approach ensured that each claim is assessed accurately, respecting the unique terms agreed with specific providers.
Kev Benefits Realized
The strategic overhaul and SymKey implementation delivered several compelling benefits:
- Increased Accuracy: The precise alignment of claims with contract-specific deadlines virtually eliminated the erroneous denial of claims.
- Operational Efficiency: With the removal of faulty configurations, the claims process became smoother and faster, significantly reducing cycle times.
- Reduced Administrative Strain: The automation of nuanced adjudication rules reduced the need for manual interventions, allowing staff to focus on more critical tasks.
These enhancements have empowered the organization to not only meet but exceed their operational efficiency goals, significantly reducing administrative burden and increasing accuracy.