You find out from billing that a growing number of processed

You find out from billing that a growing number of processed claims are returning as denied. Upon further investigation, you find that the root cause seems to be the inconsistency of checking eligibility of patients.

Goal – Develop a solution to reduce the number of denied claims and that utilizes the team more to assist in accomplishing the goal.

1. Opportunity for Improvement (Problem Statement):

2. Who needs to be given opportunity for input?

3. Decision making process:

4. Recommended Action Steps:

Solution

Ans:-

1.As number of processed claims are returning as denied is growing day by day. It seems that some where problem is laying in it. So it is important to find out the root cause. Again the root cause found inconsistent

This problem need to be shot out .So before processing the claim it is important to study the eligibility criteria that which claim to be processed. And each claim needs to be accompanied with proper documentation. Claim processing system to be standardized so that it would be easy to pass through.

2. The people who are responsible to shortlist the claims and process those need to be supplemented with this opportunities.

3.

i. Claim Processing system to be developed.

ii.It should informed to all concerned to validate with better ideas.

iii. Final system to be designed.

iv. System needs to be implemented

4. Action steps are:

Etc.