Pure Genius: TPA and Hospital Collaborate to Decrease Denials and Save

Blue Shield of California wasn't the only one who needed to refine its processes; St. Joseph's also recognized that they weren't doing everything they could, too. For instance they weren't submitting their Electronic Data Interchange (EDI) with all the necessary information in all the right places, and that was causing delays on their side. "We both have to work to figure this out. My team has been very receptive to this program and it's helped us identify and improve other areas to improve such as coding," says Igram.

Davila says that by discussing this process with both sides they were able to look at the denial and appeals patterns and see different process patterns emerge, and then work to correct them.

"This is the first time in my 20 years of doing this that we are all problem-solving together and not finger-pointing," he says.

So far, the collaboration is paying off. Davila says that Blue Shield of California has seen St. Joseph Health System claims denials shift from 20.5% in 2008 to 12.2% in 2009, and their EDI cycle improved from 15.8 days in 2008 to 13.9 days in 2009.

Currently, Davila says Blue Shield of California is the only third-party payer to provide this type of collaborative approach to claims processing, however, his team recently presented this program as a best practice at a national insurance conference. Whether it takes off nationwide or not, Blue Shield of California plans to roll the program out to all 350 facilities enrolled in their network with the hope that everyone can begin to realize greater savings in this process.