Managing a Rapidly-Growing Business by Reducing Pending Claims Inventory

FirstCare Health Plans, a provider of high-quality, affordable healthcare plans across North, West, and Central Texas, used Information Builders’ WebFOCUS business intelligence (BI) and analytics platform to streamline healthcare reporting.

Implementing a new claims payment system proved daunting because FirstCare relied on two claims systems and two data warehouses during the transition, making it difficult for employees to see what has been processed, what is pending with providers, and how pending claims impact day-to-day business.

“Our membership is growing with new plans for the Texas Health Insurance Exchange, increasing the volume of claims that require manual intervention,” says Lori Wheeless, director of BI at FirstCare. “Rather than increase the internal staff members to support this growing workload, we prefer to come up with creative ways to move our inventory of pending claims through the system.”

FirstCare needed robust BI to mine information from a single source of truth. “We selected WebFOCUS for its unique guided ad hoc query and reporting capabilities,” continues Wheeless. “WebFOCUS is versatile and reports against all our data. That’s a big help during this transition as we teach our staff to create reports and access data in a self-service environment.”

New BI dashboards reflect current claims volume, revenue, membership, expenses, medical loss ratios, and other important variables. Key performance indicators (KPIs) tie annual goals to revenue, membership, and administrative expenses. Managers track their department’s progress using red, yellow, and green indicators to spot trends, with an executive summary to obtain a high-level view by department.

WebFOCUS has helped increase claims processing efficiency, driving greater satisfaction and loyalty among members and providers.

A New Era of Analysis

Since acquiring WebFOCUS, Wheeless and the BI team have focused on operational reporting for the company’s health insurance arm. They created a claims inventory dashboard to track unanticipated issues such as claims not paying correctly or claims stuck in the system. Every day, claims processed in the old system are moved to the data warehouse supporting the new system. Departmental leaders review these backlogged claims through a WebFOCUS dashboard.

Timely payment of claims is crucial. “However there are half a dozen different steps that can cause a claim to fall out of the payment process,” notes Wheeless. “Now these workers can click on a claim and drill through to see the details as necessary. They don’t have to log into another system or do additional research. They can see it all visually displayed through the dashboard.”

Another dashboard tracks claims from the time they leave the clearinghouse until they are put into core payment systems. Employees can drill down to details as needed. BI architect John Dowd developed this dashboard using WebFOCUS assets – standard graphics, gauges, and drill-downs - right out of the box, with assistance from Information Builders Professional Services. “Information Builders helped me develop the guided ad-hoc reporting environment,” he recalls. “The consultants also created a top-ranked ad-hoc reporting environment that lets people view and analyze top paying claims, top members, claim dollars, and other important metrics.”

Driving Efficiencies Based on Metrics

Metric dashboards display KPIs from claims, finance, in-patient care, pharmacy, sales, and other departments. “For example, the sales department wants to stay abreast of membership numbers,” Wheeless explains. “Finance wants to track monthly revenue, view a breakdown of medical loss ratios, monitor pharmacy payments, and tally up administration fees and expenses.”

A business analyst helped Dowd define the data elements and suggest how metrics might be visually represented. “WebFOCUS makes it easy to connect new data elements to the existing BI environment,” he notes. “I have worked with other BI tools that are very cumbersome by comparison. I was pleasantly surprised with how easy it is to connect WebFOCUS to a database and deploy new BI functionality to users.”

Power users from key functional areas were enlisted to run reports about overall membership, medical loss ratios, total revenue, internal claims processing, claims holds, and more. “Our users are very enthusiastic about these KPIs because they have not been able to get their hands on this information before,” Wheeless says.

A Dramatic Improvement in Claims Processing Efficiency

At the project’s start, FirstCare had 80,000 claims pending. After automating the process, it reduced that number to 6,000. “In addition, our adjusted inventory was more than 60,000 appeals from providers, generally for claims that they felt had not been paid correctly,” she says. “We got that down to close to 10,000. Dealing with these backlogs improves retention and satisfaction among the provider network.”

FirstCare also entered the Texas Health Insurance Exchange. The Affordable Care Act requires plans to offer coverage to all applicants irrespective of preexisting conditions. As new members with chronic health issues join, FirstCare recommends preventive services and tracks claims related to those conditions, which could help to lower the number of bed days and reduce hospitalization costs.

Growing self-sufficiency among users has the BI team responding to fewer report requests, freeing up members for new projects. They are gradually migrating away from Crystal Reports, using WebFOCUS wherever possible. Disparate reports and data have been unified into one cohesive view.

BI Roadmap: Mobility, Data Visualization, and Predictive Analytics

FirstCare’s BI roadmap includes advanced data visualization, as well as mobile BI apps so field reps can display reports and dashboards on Android and iOS tablets. A new “member super screen” will let customer service personnel view complete member details including current and previous providers, claims history, authorizations, prescriptions, and outstanding customer service requests.

While enhancements have focused on health insurance, FirstCare also plans to create BI applications for the provider arm of the company.

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