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Payer Solutions

Achieving operational excellence through best practices

By Thomas Rekart I

Thomas Rekart is senior vice president, business management services, The TriZetto Group Inc. For more on TriZetto Group: www.rsleads. com/209ht-210

n the 1970s and ‘80s, Japanese companies exchanged employees. These employees would then return to their own firms with new ideas and approaches to improve operational performance. This practice was done in the pursuit of dantotsu. Roughly translated, dantotsu means “the best of the best.” In the business world, it means finding those companies that are the best at each of several functions and then replicating what they do within one’s own organization. The approach worked; Japanese industry flourished. Today, employee exchanges are rare and benchmarking studies too often fall short of expectations, for a variety of reasons. Apples are compared with oranges. Management sponsorship wanes. Benchmarking teams are staffed with the wrong people. Metrics are stressed at the expense of process. Or follow-through simply doesn’t happen. So how’s a healthcare payer organization to realize dan- totsu – to discover the best processes for each of multiple functions, adopt these processes and improve its financial and operational results? The answer: by engaging a business management partner who can identify best practices and implement and manage them for operational excellence. The benefits of engaging a

business management partner are numerous. Assuming the partner works with multiple firms, a health plan profits not only from its own intellectual capital but from the partner’s as well. Think of it as knowledge transfer without walls. Further, a business management partner frees a healthcare payer to focus its precious resources on innovation and differentiation. Lastly, a business management partner can deliver lower, more predictable operating costs, scalability during peak periods, higher accuracy rates and faster cycle times. To begin the journey toward dantotsu, a health plan first should choose longstanding core and noncore business functions for which established best practices can deliver operational excellence. The following functions are suggested: • Enrollment administration – group and individual setup, member enrollment, enrollment-related correspondence

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and Medicare and Medicaid state-specific enrollment processing.

• Front-end processing – mailroom processing, imaging, data entry, OCR, member and provider matching, EDI- to-image processing and image storage and retrieval.

• Claims administration – manual claims adjudication with pend resolution, adjustment processing, coordination of benefits processing and provider and member correspon- dence.

• Billing and reconciliation – premium billing and recon- ciliation, cash posting from lockbox, broker commissions, capitation administration and billing correspondence.

• Customer service – member and provider inbound and outbound call-center services for benefit explanation and verification, claims-status inquiries, eligibility verification and provider inquiries.

• Configuration services – product design and configura- tion that help build and maintain products and provider contracts, fee schedules, code sets and health incentive programs.

Second, the health plan must choose a business manage- ment partner. Bear in mind, the ideal partner will be one that has touched many organizations, evaluated numerous operations and hence discovered prevailing best practices. So, the partner should bring a long track record with a broad base of clients. Fifteen-plus years of work with dozens of clients, supporting millions of lives, handling tens of millions in claims – all of this is indicative of a strong track record. The best partners also have client councils and user groups that encourage open, candid dialogue and provide input to continuously improve operational processes. A good partner will follow a roadmap for specific, continu- ous improvement of its services for clients. It will walk the talk, investing in the continuous improvement of the staff that serves its clients.


A business management partner should offer “flexible delivery models.” In plain English, the partner should be able to manage a client’s business functions on a full-time, ongoing basis or augment the client’s staff intermittently, as needed. The partner should offer “flexible sourcing models,” as well Continued on page 29

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