Ops_571_Week_5_Individual_Ass_Process_Improvement_Plan

Process Improvement Plan Danitza Santini-Vazquez OPS/571 October 26, 2010 Dr. Alex Kadrie During the last week of this class, this author created a flowchart to observe the flow of work through the process. The steps revealed practical information needed to initiate and successfully carry out process improvements activities. We collected the data to determine a more effective way to manage the time and analyzed the complexity of appealing medical claims. The purpose of the flowchart was to obtain an accurate picture of the functional process of appeals and expand capacity and productivity in the workplace. The process improvement plan can be used to explore the procedures of the appeal department in the medical billing business. Unfortunately not all businesses are geared to follow the steps to improve their capacity. This document discloses the terms and benefits of process improvement plan. A process is any part of an organization that takes inputs and transforms them into outputs that, it is hoped, are of greater value to the organization than the original inputs” (Chase, Jacob & Aquilano, 2006). The process defines the factors that we need to consider to produce an output which in many cases could be a service. The processes is key essential in the workplace for instance, processes can determine the cost and time of the materials, the costs associated with the preparation of one service and the time on what we offered the service. Process analysis at job reinforces the accuracy of the tasks. The purpose of this document is to establish process improvement goals, assigning responsibility, planning the actions to achieve the best accurate claim, allocating the resources to submit the correct information, and actively monitoring and facilitating successful performance against the plans. The task that we intend to improve and performed daily is; the reconsiderations and appeals to the insurance as a method to collect money from policies or insurance carriers to our medical providers. The utilization of processes in medical billing facilitates the way to collect outstanding balances faster. The process improvement plan intended to eliminate the bottlenecks in the appeal’s process. An effective appeal should be direct without wasting of time, people and materials. For instance, once we receive the Explanation of Benefits from insurance companies the appeal claim should be sent out within 45 days of receiving the check to request the reprocessing of those rejected claims and collect any outstanding money. The key factor in the workplace is the organization. The organization is determined by qualified individuals or team members that understand the appeals process and meet the time limit to complete the task. Our appeals departments rely on four employees to distribute work between the different insurance carriers. The most common insurances and most worked are: (UHC, BCBS, CIGNA, AETNA, MEDICAID, MEDICARE and HUMANA). The effective way to distribute the personnel is: select one employee for the governments claim, one employee for HMO accounts; another employee for commercial and PPO accounts and the last one for miscellaneous account (miscellaneous will included all other insurance). See table below: Employees | Employee 1 | Employee 2 | Employee 3 | Employee 4 | Insurance | Medicaid and Medicare | HMO accounts: Aetna HMO, Humana HMO, etc. | PPO accounts and Commercial accounts. | Miscellaneous accounts. | Quantity of Explanation of Benefits and task to perform. | 45-50 EOB’s per week – will work complementary and send out appeals and reconsiderations. | 30-40 EOB’s per week -will work sending out appeals and reconsiderations | 40-60 Explanation of Benefits per week- will work sending out appeals and reconsiderations. | 20-30 EOB’s per week- will work sending out appeals and reconsiderations. If free time will help other employee to get the job done. | This guide should be used weekly except at the end of month, where the priority will be on posting payments to balance the month with the bank statements. Once the payments are entered into the system, the employee should continue to performing the appeals process. Forecast Reports with quantity of claims billed should be proved monthly to maintain the quality controls of the claims and to be acquainted with the payments collected and to report the audits of how many claims still pending and waiting for reprocessing. “The first step in causal relationship forecasting is to find those occurrences that are really the causes. Often leading indicators are not causal relationships, but in some indirect way, they may suggest that some other things might happen.” (Chase, Jacob & Aquilano, 2006) The organization should manage yield by establishing decision rule by running reports as a function of expected payments. “A common approach is to forecast demand over the planning horizon and then use marginal analysis to determine the rates that will be charged if demand is forecast as being above or below set control limits around the forecast mean” (Chase, Jacob & Aquilano, 2006). Control Limits The company needs to proof the quality of claims that are billing out. Take claim by claim billed to the insurance can be very expensive. The company could take monthly reports (small samples) to periodically check that the process is in statistical control. “We say that a process is capable when the mean and standard deviation of the process are operating such that the upper and lower control limits are acceptable relative to the upper and lower specification limits” (Chase, Jacob & Aquilano, 2006). The quality of the process is monitoring by control charts calculating the mean and standard deviation on where the upper and lower control limits are two horizontal lines drawn on the chart. If data points fall outside of these lines, it indicates that it is statistically likely there is a problem with the process. For example if we use the appeals monthly reports of our four employees with this data: 45,35,40,30 = 150 claims/4= 37.50 (Which is the mean of the result). Then subtract the mean from each data point and square the result. Example: 37.50-45^2= 56.25. 56.25 | 6.25 | 6.25 | 56.25 | | | | | | | | take the square root of 31.25 | 5.59017 | standard deviation | Control charts are an efficient way of analyzing performance data to evaluate a process. “Statistical quality control is a vital topic. Quality has become so important that statistical quality procedures are expected to be part of successful firms.” (Chase, Jacob & Aquilano, 2006). Statistical control in medical billing can be used the appeals department to report the increase in payments and to set up specifications. Based on that documentation, managers could measure the employee’s performance and target the company vision. If the reports go out of control the study may prevent future problems and helps to redesign the process. The early detection of error helps on the implementation of structured jobs, improve technology, and change the culture that need to be change. Then documentation is also important to show the claim’s trend and provided the resources need it to implement the productivity. The process improvement plan should stabilize process, satisfy customers (providers) and reward the employee. The calculation and data should identify possible changes to make further, standardize the process and monitoring process performance. References Chase, R.B., Jacobs, F.R., & Aquilano, N.J (2006). Operations management for competitive advantage (11ed.). New York: Mc Graw- Hill/Irwin.