Partnering with Providers to Improve Member Service

Blue Cross and Blue Shield of Illinois

In today's managed care environment, out-of-sync work processes and poor communication are common barriers to the efficient delivery of healthcare services.  Cooperative, creative efforts of health plans and providers can yield high-value, low-cost improvements to administrative processes that benefit plans, physicians, and members alike.

Program Elements

• Blue Cross and Blue Shield of Illinois (BCBSIL) found an opportunity to improve administrative efficiency by addressing a problem first identified by members.  Complaints and member survey responses indicated significant dissatisfaction with claims processing. 
  
  
• Claims processing is the joint responsibility of BCBSIL and their capitated Medical Groups/Independent Practice Associations (MG/IPAs).  Communication between the plan and the MG/IPA is central to a seamless member experience with timely and accurate claims payment. 
  
  
• In response, BCBSIL formed the Claims Payment Workgroup, composed of BCBSIL staff and MG/IPA representatives.  The Claims Payment Workgroup evolved into the Medical Group Advisory Committee as it tackled administrative problems (including past due claims processing services) that plagued BCBSIL and the MG/IPAs. 

Program Results

• Through Committee discussions and input from the MG/IPA representatives, significant flaws in the work process were identified. 
  
  
• After replacing or repairing defective fax machines, the Committee implemented a daily fax communication to each MG/IPA, even when no past due claims were reported. 
  
  
• To improve reply communication, BCBSIL customer service staff were trained to accept a broader range of responses from the MG/IPAs, including responses about claims for capitated services without a check number and date.
  
  
• Claims handling improved dramatically:  past due claims sent to MG/IPAs for review dropped from over 8,400 in the first quarter of 2002 to only 816 in the same period of 2005. 
  
  
• Claims paid by BCBSIL due and deducted from the MG/IPA capitation dropped 64% between 2001 and 2004. 
  
  
• In the 2005 Consumer Assessment of Healthcare Providers and Systems survey, 83% of members agreed that their claims were handled in a reasonable amount of time and 87% agreed that their claims were handled correctly, up 31% and 26%, respectively, compared to 1999 survey results.

Contact  

Jeanne Trumbo, Provider Affairs, 312-653-3754, trumboj@bcbsil.com