Greater Claims Data Scrutiny Could Save Hospitals $800M

For the past three years Blue Shield of California and hospitals that are part of the Hospital Association of Southern California (HASC) have taken an extraordinary step to resolve claims denial issues—they've shared information!

That might seem like a no-brainer. But the rule has been (and still is in most circles) that health plans don‘t share very much information about claims processing with hospitals. For years the two suffered more or less in silence as unresolved claims ping ponged between hospitals and Blue Shield.

Eventually the two sides began talking about their mutual frustration with the inefficiencies in the claims process. From those discussions Blue Shield developed its Partnership in Operational Excellence and Transparency program. POET is a web-based analytics portal that consolidates claims data on password-protected dashboard to provide 36 months of claims data, including cycle time, submission details, denial percentages, and appeals information to 175 participating hospitals.

The payer-provider combo has reduced claims denials from 22.8% to 17.4%, cut the claims cycle time from 31.9 days to 28.1 days, and increased the electronic transmission of data from 85.2% to 90.3%.

The program has produced about $8 million in administrative savings for hospitals so far according to Kenny Deng, senior director, provider relations and operations for Blue Shield. Savings are related to the lower labor costs per completed claim, faster claims payments to the hospitals, and a reduction in the number of resubmitted claims.

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