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Case study
Healthcare case study

TriZetto Provider Solutions Eligibility solution reduces write-offs by 44%

A professional services organization headquartered in the northeastern US saw an increase in front-end claim denials from receiving improper and inaccurate registration information. Within six months of going live with the TriZetto Provider Solutions® Eligibility solution, it saw a significant drop in denials and write-offs.

At a glance

Industry
Healthcare

Products and Services
TriZetto Provider Solutions Eligibility solution

Challenge

Required an insurance verification coverage strategy to lower the number of denials due to missed filing deadlines and to prevent future write-offs.

Success Highlights

  • Achieved 47% reduction in timely filing denials from July–December 2022
  • Realized 44% overall write-off reduction between 2022 and 2023
  • Reduced eligibility and registration denials by 11%
  • Reduced coordination of benefit (COB) inquiries by 98%

 

The challenge

The client, professional organization providing revenue cycle management services to its parent health system, was receiving incorrect and incomplete data from hospitals and clinics which often hindered eligibility verification. Although unintentional, the manual verification process often led to missing data, incorrect patient information, inactive insurance policies and missing secondary insurers. Overall, these errors placed a huge task on organization’s staff and often resulted in lost reimbursement.

As the first step in the revenue cycle process, these errors were driving a high number of front-end claim denials due to missed filing deadlines, resulting in revenue write-offs. Many times, the client would receive the correct information after the timely filing limits for the associated claims, leaving it unable to recover the related reimbursement. The ideal eligibility solution needed to reduce the strain on the front office staff and improve front-end processes without adding additional full-time staff members.

 

Our approach

In July 2022, the client partnered with TriZetto Provider Solutions (TriZetto) to implement a multi-phase approach for adding real-time eligibility solutions to its professional services organization.

There were four primary areas to address by adding TriZetto’s eligibility solution to the organization’s processes:

  • Accurate benefit coverage before cases are submitted
  • Effective stop gap process to create case holds for inactive or rejected responses
  • Correct decision-making processes driven by actionable insights from the eligibility solution to determine active coverage, benefit coordination and demographic updates
  • Updated eligibility status for accounts receivables with the option to check eligibility again if it received an inactive response
our approach

“Without buy-in from the team and the top-down mentality at our organization, we wouldn’t have been able to successfully implement this solution. It took everyone in our organization, from front-office staff to back-office staff, to be able to make this an actionable item inside of our organization.”

-Data Integrity & Project Management

Introducing the TriZetto Provider Solutions Eligibility solution

TriZetto’s Eligibility solution has transformed the organization through gains in operational efficiency, reliability of data validation and increased payer remittance. It is now the cornerstone of the client’s revenue cycle process and used as the foundation for all patient and staff validations.

With the solution, the organization was able to create six new write-off categorization buckets to prioritize write-off reasons. Because of the new categories, untimely filing is no longer the top denial or write-off adjustment.

The new solution allowed for correct information to flow through before patient check-in, mitigating delays that previously caused many denials. The business can now get the correct filing out on the initial submission to get clean first claim validation.

“The eligibility portal is a gamechanger to our reimbursement process!”

-Manager of Chart Acquisition

Business outcomes

The eligibility solution has had a positive impact on clean claim submission and reimbursement for all patients. Accounts receivable has seen the greatest benefit from implementing eligibility across the organization.

Write-off reduction

Registration errors, which have historically accounted for 40–50% of its denials, was the number one write-off bucket. After going live with TriZetto’s Eligibility solution in 2022, timely filing denials made up 26% of the total write-offs/adjustments. By the end of third quarter, timely filing had decreased to only 1%, a 25% decrease. It’s no longer the top bucket.

During the third and fourth quarters of 2022, the client added additional write-off categorizations. After analyzing the first six months of eligibility go-live data from July to December 2022, the organization noted a 47% reduction in write-offs due to missed filing deadlines. The data also showed a 44% overall write-off reduction for the same six-month period.

The client achieved a 14% overall write-off reduction between 2022 and 2023 through continuously reviewing the write-off buckets and using the new solution.  

Business outcome

Front-end claims denials for eligibility

During the same period from July to December 2022, front-end claims denials for eligibility and registration were reduced by 11%.

The solution has reduced  denials, streamlined payer remittance and increased the productivity of secondary/crossover claims. In addition, it has reduced administrative costs associated with generating letters including postage, printing supplies and staff wages.

Reduced inbound phone calls

Inbound patient phone calls for primary payer inquiries have been greatly reduced by the client’s use of the new eligibility solution. 

Calls about verification and plan coordination have also declined.

  • There’s been a 98% reduction of coordination of benefit (COB) inquiries
  • Guarantor requests for information to determine if the patient has insurance benefits and coverage has decreased
  • Payment posting has had to generate less COB requests for verification of primary and secondary payers

Conclusion

The organization strives to provide outstanding patient experience and satisfaction. It aims to minimize patient stress and anxiety by limiting patient engagement post-procedure including eliminating phone calls and coverage letters, as well as streamlining revenue processes. This is possible because of stronger front-end processes and the TriZetto Eligibility solution that allows for verification checking before the time of service and timely claims filing.

About client

This professional services organization headquartered in the northeastern US supplies revenue cycle management solutions for services rendered by its parent organization.

The parent organization employs 2,000+ specialty and primary care physicians and healthcare practitioners, including medical school faculty members, who provide services across the health system and other hospitals in  the region.

Call-out client quote:

“TriZetto’s Eligibility solution has caused a marked difference for our organization. We have been able to run real-time eligibility, giving us an assurance that what we are sending out the door contains the most up-to-date and accurate information.”

-Manager of Chart Flow Operations