Silos: Great for Farms, Not for Healthcare
By Mitesh Kumar, Senior Vice President – Claims Practice
Silos make sense on farms. In healthcare, they can lead to disaster.
Nevertheless, those of us who use healthcare—providers and patients, payers and members—or work in adjacent businesses are forced to deal with silos every day. This is especially true when it comes to the claims process. Claims information is often found across several data silos.
Each time we visit a healthcare provider, a claim is created. From there, its route is circuitous at best. At worst, a convoluted journey that passes through a series of data silos, finally getting resolved after being touched by multiple systems, people, and departments. Most dashboards today simply offer user metrics and highlight existing problems like pend rates and rework.
Claims silos become an enormous problem quickly considering that payers process 5 billion and deny 850 million claims every year.
Thankfully, there’s a better way.
Mapping Complex Journeys
Progressive BPO solutions use process mining to map out complex claim journeys—along with insights from a team of experts—to help healthcare businesses understand where and why problems occur. It provides a single view of how a claim flows through the organization, and where, why, and what causes it to get stuck in the process.
For example, if the provider’s appeal rate is high (delayed or incorrect resolution can impact Star Ratings), a tech-enabled solution can use process mining to visualize the end-to-end journey of an appealed claim. Process mining helps you understand where and why problems occur through a single, real-time view of how a claim flows through the organization. By mapping claims data upstream and downstream, a payer can gain insights working with an experienced team to understand where, how, and why the claim was denied and work to improve the process to lower the number of unnecessary appeals.
A bonus of a tech-enabled solution is its ability to build a timeline and sequence of each activity, which can help payers identify intervention opportunities to prevent similar appeals in the future.
This new examination of claims supports process flows, rather than creating an environment where the claim is destined to bounce from silo to silo.
Break Down Silos with Process Mining
Process mining breaks down siloes by using system data to examine and locate areas for improvement. By revealing how processes truly function—where they excel and where they lag—process mining helps organizations identify inefficiencies and streamline workflows. The method identifies hidden patterns, which provides a better understanding of how processes are executed. This helps organizations understand where improvements can be made.
As operational silos are removed, payers will experience several immediate advantages. Easily accessible data and processes serve to improve business and operational processes, as well as member and provider relationships.
When breaking down operational silos these benefits are created:
Reduce Provider Abrasion: Streamline processes to identify critical touchpoints, improving communication and transparency with providers.
Fast Turnaround Times: Establish process models that pinpoint optimization opportunities, accelerating the claims processing cycle, which reduces provider and member abrasion.
Improve Operational Efficiency: Create significant reductions in administrative costs, benefiting all stakeholders in the healthcare environment.
Decrease Late Claim Payment Interest: Restructure workflows to prevent avoidable delays and identify bottlenecks, which result in lower interest payout.
Using this extremely efficient solution, coupled with input from dedicated experts, streamlines the claims process, eliminates gaps and redundancies, and supports transparent communication and seamless information exchange with members.
The best part? This approach removes the silos by strategically addressing everyday and exceptional issues that plague the claims process. By doing so, payers positively impact all stakeholders, and the result is immense: It improves payer’s operations, reduces provider abrasion and enhances the member experience.
Fostering these improvements is the ultimate goal for each of us who work in healthcare.
Mitesh Kumar is Senior Vice President of Practice at Sagility.
This article originally appeared in Healthcare Business Today.