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Optimizing claims payment for successful risk management.

Janice Frates¹, Mary Jo Ginty, Linda Baker

¹Health Care Administration Program, California State University Long Beach, Newport Beach, California, USA.

Healthcare Financial Management : Journal of the Healthcare Financial Management Association

|May 17, 2002

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Addressing issues in managed care payment systems is crucial for provider satisfaction and financial health. Analyzing the root causes of delayed claims payments can improve efficiency and reduce costs.

Area of Science:

Healthcare Administration
Health Economics
Health Information Systems

Background:

Provider and vendor dissatisfaction with managed care payment systems often stems from disputed claims and delayed payments.
Timely and accurate claims processing is vital for maintaining provider/vendor satisfaction, financial stability, and regulatory adherence.

Purpose of the Study:

To analyze the underlying conditions contributing to late claims payments within managed care systems.
To identify operational, billing, contracting, information system, and human resource management issues affecting payment timeliness.

Main Methods:

Focused analysis of factors contributing to delayed claims payments.
Examination of provider, vendor, and payer operational procedures.

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Main Results:

Delayed payments and disputed claims are primary drivers of dissatisfaction.
Identifying specific issues in operational procedures, billing, contracting, IT, and HR can pinpoint causes of delay.

Conclusions:

Resolving identified issues empowers claims processing staff to handle problem claims efficiently.
Prompt resolution of claims issues leads to reduced operational costs and improved satisfaction.