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ACA and ICD-10 spell trouble for claims paying operations

November 25, 2013
From the November 2013 issue of HealthCare Business News magazine

Optimizing the Performance of Manual Claims Processors
One of the biggest issues that allows gaps to form between actual performance and potential performance is the traditional approach to managing by metrics. In organizations where employees have explicit or implicit targets, some employees view the target as a cap on maximum productivity. They may take shortcuts to hit their target, and they may stop working once they get there. Meanwhile, when employees miss targets, it is often unclear why or what to do about it. As a result, managers tend to focus on outlier employees with substantially worse performance. They get the worst of the worst to be only bad, while many other average employees receive no support to become great at their jobs.

To increase output across the team, employers will need to start looking beyond metrics to understand the actual work that employees are doing. By understanding employee work habits, the processes they follow, and their patterns of work over time utilizing technology, managers can make three key changes. First, they can define and enforce their best practices, which ensures high quality and prevents people from taking shortcuts. Holding people accountable for process as well as output is the only way to manage quality. Then,employers can set meaningful targets based on what someone should be able to do, rather than to operate from historical averages that tend to understate performance. Finally, employers can identify improvement opportunities for all employees who aren’t reaching their potential.

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Pressure is coming to claims payers in the form of the ACA and ICD-10. These changes will create more work and more complications regardless of how well-prepared payer organizations are. As a result, payers are going to be forced to make rapid productivity improvements, or miss their Service Level Agreements. The good news is that most organizations still have the potential for meaningful productivity improvements in their manual claims paying operations, provided they make the right technological investments to help managers help their processors reach their potential.

Daniel Enthoven is chief marketing officer at Enkata, which provides SaaS applications to optimize employee effectiveness in call centers and back office operations. With 20 years of technology and call center experience, Dan was an early employee of Nuance Communications, and worked for Monster. He has a BA and an MBA from Stanford University.

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