Client Results: Increasing Claims Auto-Adjudication for an MSO

We improved procedures for processing authorizations, resulting in higher auto-adjudication and increased productivity.

Challenge

The client needed to streamline their claims authorization process to increase their efficiency, quality and productivity. Their authorization backlog continuously surpassed their capacity, creating a “bottleneck effect” of compliance risks, overtime expenses and a poor provider experience. The organization averaged more than 50 requests a day with a capacity of 40 authorizations per day.

Solution

ProspHire drove a current state assessment of the client’s authorization procedures. They measured process performance by conducting in-depth stakeholder and member interviews, assessing department resource allocation, mapping out all impacted dependencies and identifying gaps and inefficiencies. They then developed a streamlined process that reduced processing time and eliminated duplicated efforts across departments. ProspHire trained the client on Provider Portal tool best practices for completing and submitting authorizations to increase their auto-adjudication rate, ultimately reducing the backlog. They also developed workflows to escalate urgent requests and efficiently process authorizations not submitted via the Portal.

Result

As a result, ProspHire helped the client achieve their highest percentage of autoadjudicated claims to date (~85%) and decrease the amount of authorizationrelated phone calls to customer service. By implementing ProspHire’s process maps, the client also increased productivity and improved turnaround time and compliance for both urgent and non-urgent requests. The organization saw incremental time and cost savings, as well as increased provider and member satisfaction with the enhancements to the Provider Portal.