Successes - UMR (Formerly Fiserv Health)
Prominent Third-Party Administrator uses Fortis to create a more efficient claims process

UMR, a UnitedHealthcare company, is the largest third-party administrator (TPA) in the country. The organization works with more than 150 PPO and PHO networks, including UnitedHealthcare’s national networks. UMR processes more than 40 million claims a year, valued at more than $10 billion. They serve more than 1,260 clients and almost 3 million plan members.

UMR’s Inventory Control Unit (ICU) typically receives 300,000 documents per month from health care providers, insured members, and other organizations. Previously, this mail was sorted manually and paper batches went from the distribution team to staff members based on the claims group for which they were responsible. There was no automated workflow and no easy way to track supporting documents related to a claim as they were received. “Because of the volume of mail and faxes UMR receives, searching through paper files was inefficient and time consuming,” says Corina Bravi, Inventory Control Unit manager. “It could be difficult to monitor the progress of each claim or to quickly locate documents associated with a specific claim.”

UMR’s goals in implementing document management were to minimize the time it took to get claims and associated documentation from the distribution department to the claims team researching the issue. The organization also wanted to make documents readily available for the customer service team if they received a call about the status of a claim. “Another objective was to get paperwork off desk tops and to get documentation processed as quickly as possible,” says Bravi. “We needed a way to track the amount and type of incoming mail we receive and to be able to calculate turnaround times for our production reports and random quality checks. We wanted to decrease the time between when a claim is received to when it is validated and paid.”

Solution
An Inventory Control Unit was created in October 2007 and the Fortis document management software implementation began concurrently. By February 2008, Fortis was up and running. The project was planned, created and implemented in ninety days. “We estimate that we will achieve 120% ROI within one year of implementation through these process improvements,” Bravi says.

With Fortis, incoming mail is separated into document types, batch indexed and then scanned into the Fortis repository. Then the document is categorized by work type and group and sent to the appropriate electronic queue. The claims representative receives the information and enters additional index fields when they research the claim and prepare it for a claims analyst. The images are indexed with claim numbers, group numbers, and work type. Fortis queries pull these images according to type or group. Each day, the departments go in and open their queue to find documents that have been imported for processing. After a document has been worked, they have the option to change its status to Complete, Pending, or Denied. This image is available for all authorized users and can be retrieved if someone needs to refer to the document.

“This process also allows us to run production reports to evaluate entire teams and each member on that team. If we have a performance guarantee for a group, we can run reports by group to see a specific group’s turnaround time,” Bravi says. “This has helped establish goals within the team to improve quality and quantity of work completed.” Fortis has extensive reporting capabilities to find and track all claims and supporting documentation received on a daily basis. The reports can also identify patterns, for example the number of appeals a group receives for denying a claim incorrectly.

UMR reduced the average turnaround time for processing incoming documents related to a claim from 30 days to 6 days. UMR also dramatically increased their ability to track documents they receive and report on each step in the claims preparation process. UMR is using this information to meet quality benchmarks set by a performance guarantee group that enables continuous process improvement. Documents are brought into an electronic system upon receipt and are immediately indexed and searchable.

Documents are immediately on hand for the different departments to access and the information is readily available in the system to create ad hoc reports. Customer service representatives have access to documents instantly and no longer request duplicate information unnecessarily due to a question about whether or not a document has been received. Staff has been reallocated to more strategic activities due to the streamlining of the indexing process and no longer needing multiple people to sort and distribute mail manually.

Now when customers contact the UMR call center, the customer service representatives have immediate access to the original source documents. Implementing Fortis helped various departments to create a workflow process that is ultimately paperless. Another advantage is the accelerated implementation of UMR’s claims processing Workflow Distribution System (WDS). The WDS system allows UMR to route the electronic portion of the claims directly to a claims analyst’s desktop for processing. The analysts use Fortis to access the original source documents whenever they need them for confirmation.

The success criteria include security of private health information to meet HIPAA regulations, cost savings realized because of first-touch resolution of customer calls, avoiding the cost of redundant handling of the same issue, and minimizing the risk of loss of discounts and the risk of performance guarantee penalties due to delays caused when documents needed to process a claim couldn’t be accessed immediately.  But, most important is the intangible effect on customer and client relationships. “When customers were required to send information multiple times, we lost credibility and this caused a great deal of dissatisfaction at every level of our business -- from the customer up to the CEO of our client group,” Bravi says. “This seemingly small ‘intangible’ left unresolved could result in the highly tangible loss of clients. Our emphasis is on superior customer service, so the perception that we were ‘losing’ information was not acceptable.”

The Fortis implementation resolved UMR’s concerns in several areas, including prompt pay issues and greater ease in securing private health information. The project has allowed a faster handling of incoming information and its availability to the appropriate person to complete the claim or request. In addition, private health information is centralized, protected, and only accessible to authorized users. Protecting customer privacy is an important part of meeting UMR’s goal of providing superior customer service.

>>Click here for printable PDF