In today's competitive healthcare services environment, providers are looking for any way to gain a financial edge. Margins are decreasing, cost-cutting initiatives are in place - yet hospitals, clinics and practices may be leaving a tremendous percentage of top-line revenue on the table.

Imagine you are a regional hospital or large multi-office practice with $120M in annual revenue and 50% managed care penetration. You might well be forfeiting $3 to $5 million of almost pure profit due to inappropriately denied claims and underpaid services. Would that get your CFO's attention?

Claims denials and underpayments mean a healthcare provider isn't being paid by an insurer, whether the reason is valid or not. This presents the provider a great deal of additional back offices process, including records research, phone calls, paperwork and correspondence. When these denials stack up in the billing department of a busy organization and the older documents are pushed to the bottom of the pile, it often means that rightful compensation is never fully recovered. In fact, studies indicate that on average, providers do not collect between 3% and 5% of revenues entitled to them, and that even a moderately successful claims denial management initiative can add an average of 1.4% to operating margins - a godsend considering the recent flattening of margins below 1% for many hospitals and large clinics.

KMA Claims Scorecard provides your organization's management team with visibility into the claims denial process. Serving as a nexus for managing revenue collections, it allows you to identify problems as they occur, assign appropriate resources to address them, and adjust business processes to improve long-term performance.

What's happening in my organization?

The claims scorecard will provide valuable insights by addressing critical questions such as:

	Which payers consistently have the highest denial rates by numbers or dollars? Which have the lowest denial overturn rates?
	What are the top reasons that claims are being denied?
	How are denied and underpaid claims currently trending? How many denied claims are currently outstanding/unresolved?
	How much interest am I owed from each payer due to late payments?
	How does this week's overall denial rate compare to the prior four?
	What claims trend might affect future revenue projections for my organization? How do I account for variances from historical/projected denial rates?
	Which procedures or departments have led to the most denied claims during the past 3 months?

With questions like these, providers are now beginning to quantify the denial problem - i.e. what is it really costing our business? In response, healthcare providers are looking at ways to streamline and accelerate responses to claims denial - implementing denial recovery teams, appointing claims denial managers, and reviewing payer contracts and relationships.

Leveraging Claims Information

KMA Claims Scorecard offers the leadership team at a hospital, clinic or practice with the data they need to identify claims problems, spot trends, and work with financial and medical personnel to reduce both denials and underpayments.

Specifically, the scorecard provides:

	A visual snapshot of key performance indicators (e.g., claims pipeline status, outstanding payments), using a stoplight (red, yellow, green) dashboard metaphor.
	Numerous graphs to help managers identify where performance is lagging or improving (e.g., weekly and monthly trends in denial rates by revenue center).
	One-click drilldown to detail reports (e.g., denial rates by procedure), allowing managers to investigate problems in detail.

A Cost Effective Solution

Many hospitals find it difficult to invest in new technologies or capital projects, especially large and expensive enterprise software systems, regardless of the returns they promise. However, implementing a claims denial dashboard can cost-effectively improve operating margins by 1-2% within a year, freeing up funds for investment in larger scale initiatives. Our customized solution allows you to keep your existing software systems in place while harnessing the information within them to capture much of the value that expensive and slow-to-implement replacement systems might provide for denial management.

Creating a Consolidated Solution Environment

Active claims management requires the right information at the right time at the right level and in the right format. In order to make effective and timely decisions, executives, managers and staff require access to up-to-date information integrated across different operating systems and multiple database platforms. A centralized claims dashboard can form the basis for operational changes, such as setting performance goals based on revenue integrity.Denial data could also be merged with clinical-performance reports to highlight possible correlations between denials and issues pertaining to clinical performance. KMA's Claims Dashboard allows islands of claims information to be disseminated transparently throughout an organization in real time.

By leveraging Microsoft's suite of integration products and familiar set of analysis and reporting tools, the full power of Business Intelligence for claims management can be realized. A typical system will contain an OLAP data mart leveraging the Microsoft SQL Server platform to provide drill-down and drill-through capabilities for business analysis.

The system is designed to offer business users real-time access to the data warehouse, to query and analyze their respective spend data and a company's cross-business spend data globally via a selection of Microsoft scorecarding, analysis and reporting tools.

Further, the solution leverages a Microsoft SharePoint Portal interface for information delivery, offering organizations secure, personalized delivery of reports, charts and business data. SharePoint's inherent document management and collaboration extend the solution's capabilities to provide a platform for "actionable information" - allowing virtual teams to share documents, insight and tasks associated with the business data.Integration with Microsoft Active Directory offers consistent organizational security and authentication - leveraging your business investment in network and security infrastructure and providing the right information, at the right time, to the right people.

Claims Analyzer Solution Components include:

	Microsoft SharePoint Portal Server for delivering the scorecard
	Microsoft Business Scorecard Solution Accelerator to provide the dashboard
	Microsoft SQL Server for database repository
	Microsoft SQL Server Data Transformation Services
	Microsoft SQL Server Analysis Services
	Microsoft SQL Server Reporting Services