A Stronger Community, a More Stable Provider Network
For the Community Health Plan of Washington (CHPW), a claims backlog undermined the trust of both service providers and members.
The CHPW overhauled its processes to pay claims faster and more accurately, accelerating provider cash flows to better ensure their network allegiance as well as the high quality of their member services.
Business Needs
US healthcare plans that serve lower-income Medicaid patients typically offer lower reimbursement rates for service providers than commercial insurers. That can make it hard to contract with doctors and other medical professionals. Despite this, many medical groups accept Medicaid patients as a way to give back to their communities. But this altruism can become strained if the payments are late or inaccurate.
Such was the case years ago, when the Community Health Plan of Washington (CHPW) faced both those problems. That changed with assistance from the NTT DATA Services Consulting and Business Process Outsourcing teams. Today, CHPW enjoys a solid reputation as one of the best Medicaid payers in Washington State and regulators often seek advice from them when they plan to modify existing guidelines and regulations or roll out new ones.
To serve approximately 270,000 members, CHPW supports a network of 20 community health centres that operate more than 130 clinics across the state. Its network consists of over 2,500 primary care and 14,000 specialists as well as more than 100 hospitals. As a not-for-profit enterprise who believes in the power of community, it invests all its excess profits back into the health centres, so they can continue delivering high-quality care to anyone who walks through their doors.
Outcomes
- Provides timely provider payment: > 99% 30-day turnaround time vs 95% standard
- Exceeds payment accuracy: 99.47% vs 99% SLA
- Reduces claims backlog to < 2.5 days
- Boosts competitive positioning
- Enhances member and provider satisfaction
- Provides scalability for growth
- Strengthens brand reputation
Solution
Keeping providers and members satisfied
According to Alan Lederman, CHPW’s chief operating officer, CHPW provides a safety net for the state’s underserved and low-income communities. “We have to be efficient, effective and timely in paying our providers, because we can't pay them top dollar for care and coverage. We also must be easy to work with because their time is so valuable. Both providers and members have other options, so our speed, accuracy and excellent customer service are what set us apart.”
Before engaging NTT DATA Services, CHPW had organisational ties with a third party that managed its claims and payments. “Problems arose because it was hard for CHPW to access all its data, and system maintenance was slow and inefficient,” Lederman says.
To remedy the situation, CHPW outsourced the work to NTT DATA Services to provide a software-as-a-service (SaaS) platform and claims processing. NTT DATA Services also manages data entry, mailroom services, claims processing and configuration services as part of its Business Process Outsourcing solution. CHPW uses NTT DATA Services proprietary tools which populate content into new provider and member portals as well as captures and processes claims, streamlining workflow. Both solutions are an integral part of a new Digital BPaaS for Health Plans solution.
Paying providers faster and more accurately
Today, CHPW’s claims payment system is among the nation’s most efficient. “We have about two and a half days of claims on hand, which I would put up against any plan nationwide, commercial or otherwise, in terms of consistency and accuracy of that inventory,” Lederman says.
Lederman notes that two key concerns of all healthcare service providers are getting paid quickly and accurately. “This helps set us apart from other plans that doctors and allied medical services could engage. In both categories, CHPW excels with the help of its NTT DATA Services claims payment system. For example:
- While the industry’s standard claims payment with a 30-day turnaround time is 95 percent of all clean claims, CHPW is able to achieve a consistent 30-day turnaround time of more than 99 percent to ensure that claims are paid timely to minimise any aging over 30 days.
- Over the most recent three-year period, CHPW’s payment accuracy has exceeded the 99 percent service level agreement (SLA), with a 99.47 percent financial accuracy average.
He adds, “When I compare what we were paying our previous vendors for the services to what we pay NTT DATA Services today, we've literally saved millions of dollars. This has enabled us to reduce our overall administrative expense load so much that we have one of the lowest, if not the lowest, Medicaid administration rates in the state. This allows us to generate more capital that we can then reinvest in the local community through our member health centres.”
More recently, CHPW engaged NTT DATA Services to build a new network provider directory. Before, CHPW had completely outsourced that application, including updates to a participating provider’s information. “Because they were using old technology, we couldn’t make changes ourselves,” Lederman says. “Work orders were required and changes could take weeks to get done.”
Driving innovation to stay competitive
This directory is more interactive, featuring a wide range of query capabilities for users. “The new provider directory benefits both the provider community in highlighting their attributes and our member population by enabling them to search for the services they need using everyday language and not some complicated medical jargon,” Lederman says. “And we can make most directory changes ourselves in-house.”
This kind of innovation-keeps CHPW competitive. “I consider NTT DATA Services not only a trusted strategic partner but also a trusted global innovator,” Lederman says. “They have insights to innovations happening across the healthcare industry – not just in the US but globally, too. We are confident that the advice we get from their experts is sound and reflects best practices.”
About Community Health Plan of Washington
A community-based Medicaid health plan in Washington State streamlines its payment processes, which helps stabilise and strengthen its network of providers.