Greater Claims Data Scrutiny Could Save Hospitals $800M

"We can talk to other hospitals and explain that POET is an opportunity to get faster, accelerated cash by identifying the root causes of claims denials." He explains that POET is a "process deep dive" down at the revenue cycle level and is an opportunity to work directly with the hospital staff in the trenches working and analyzing the claims. The deep dive is "like digging for gold," he says. "The gold is there. We just need to get down into the mine to find it."

While POET can be implemented with existing claims and IT personnel, Deng says the most important component is the support of senior hospital executives. He mentioned one hospital that had 59% of its processed claims denied in 2011. The hospital receives POET information and is in talks to join, but isn't officially part of the program yet.

The case represents the necessity of making sure everyone gets the information they need to be comfortable with the program. The frustration, says Deng, is that some of the hospital's claims problems are likely easily fixed.

For example, in one case, using an incorrect format accounted for 15% of the claims denied. Health plan use different types of formats for different claims, and while it sounds complicated, Deng says it's just an educational process of matching health plans, claims, and formats.

Dan Martinez, director for patient financial services at Mission Hospital Medical Center in Mission Viejo, says that once the system is up and running, it takes about an hour each month to review the claims denial data and identify trends.

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