-----(This is actually a story from 2997, I just thought it was funny)
So as part of one of my many job duties I get to meet with various departments and check their compliance to and their performance to defined goals. Most of this involves a fairly simple formula
If I were Johnny Lydon, it would be "This is what you want, This is what you get."
In my case it goes like this, "Your goal is x and you did y. If y is greater than x, then you are exceeding your goals. If x is greater than y, then you did not exceed your goal."
The one thing I know about the goals is they are based on a business model that says we have to make more money then we spend to stay in business (with a little pad added for unknown costs such as HIPAA implementation, as an example). Are goals are pretty standard for the industry.
So yesterday I had to talk with one of the billing departments. They send a {claim} to another company for payment (think medical bills to insurance companies). To make this really easy to grasp, there are 1000 claims that need to be sent each month. They range from $50 ~ $10,000 each. We have five people, so they each should send 200 per month. In a perfect world all would be sent, all would be received, all would be processed, all would be paid and all of this within around 30 days..
Shocking Update: It isn't a perfect world.
The following is an overly simplified example of the process.
Historically we know that 10 ~ 15% of them will never pay (the reasons are varied and require lengthy explanations). We know 25 ~ 50% of them will pay a reduced amount. We know 25 ~ 50% of them will pay outside of the 30 day mark (and these claims may pay a reduced amount). A claim that pays a reduced amount needs to be researched and lots of other {stuff} needs to be done to get it to pay the expected amount. It takes people calling various companies to get these paid. We know 10 ~ 15% of them will pay within the 30 day period, the expected amount and no follow up will be required.
We hope that the claims that never pay are the smallest dollars. We hope that the claims that pay without intervention are the largest dollars. It almost never works this way.
We also hope people get their 200 claims out and follow up on anything that needs additional work effort. We hope they don't spend time on the small dollar accounts when larger dollar accounts need work to get paid. We also know the smaller dollar accounts that need additional work are a lot easier to get resolved than the larger dollar accounts that need work. For the record there are defined policies on all of this that the employees see as part of their job description.
So yesterday I spend time with people to get information on how things are going. I run reports on productivity for the individuals and the department. I compare them to other departments and to last year.
This is what I find:
Not all staff are getting their 200 claims out.
Not all staff are working the claims based on the proper dollar amounts.
A percentage of claims that pays with no interaction has remained the same for a long time, and in line with industry standards.
A percentage of claims that don't pay has remained the same for a long time, and in line with industry standards.
Phone activity logs are much lower then usual
It goes like this
1) I am here today to figure out ways to make sure we hit the department goals and get the claims out the door and paid in the timeframes in the policy manual. Are you hitting the individual claims goals now?
a) No
2) Why is that?
a) We're too busy
3) Doing what
a) Working claims
4) Which ones, and in which order
a) The ones that don't pay
5) Are you working the large dollar (good ones) or the small dollar (bad ones), tell me what is being done now.
a) We're working both of them, and it takes all day
6) Well my understanding is that you work the large dollar claims until you get to {dollar amount} then you work everything that hasn't been sent. Is that what you're doing now?
a) We don't have time to do that
7) OK, well I'm not sure that is the policy, so let me help. Work everything that requires follow up as long as its over {dollar amount}. Then work everything that hasn't been sent. So don't work any account under {dollar amount} until all claims have been sent. Does that make sense ?
a) Yes.
8) So do you think you can get all the claims out now?
a) Not sure, we'll have to see.
9) OK, then make sure you tell me and your supervisor on any day you cant get anything out, is that fair?
a) Sure, if we have the time.
10) Well you need to make the time if you cant get this done, its important that we get these things done in a certain order. If you cant get something done, this really needs to be forwarded to the supervisor.
11) So does anyone have any questions ?
a) No
12) Do you think you can get this done in the order its supposed to be done?
a) We'll try
• At this point I think I am beating the dead horse, so I attempt to move on.
13) OK, next question, {person} mentioned that you cant get to the claims for {government agency}, why is that?
a) They are never open
14) What, I don't understand, when you call them, they are closed.
a) No, their lines are always busy.
15) OK, well i'm not sure that means they aren't open, it means they are busy. So you need to call back probably, I suggest calling at other times, as in off peak hours. What times are you calling
a) When we are at work
16) I realize that, what times during the day are you calling them
a) The morning
17) When you first get in at 8:00 am ?
a) Sometimes, usually later in the morning.
18) OK, then if their lines are busy in the morning, then call back later in the afternoon.
a) They are closed when we call then.
19) When you say closed, do you mean their lines are busy or you get a recording that they're not open
a) It can be either one
20) OK, do you know what hours they are open
a) 9:00 am to 4:00 pm
21) What time zone are they in
a) What do you mean
22) Where is the office you call located
a) Los Angeles
23) OK, then that is the same time zone we are in. So if they're lines a busy a lot during the morning, and you know they are open until 4:00 pm, then call after the morning and before 4:00 pm when they're open. Can you do that?
a) Sure, if I have time.
24) OK, so I am guessing that there is some other reason you cant call them, can you tell me what it is?
a) We're really busy and don't have time. We have to work all the claims that didn't pay
25) We went over this already. I think I clarified it. So is there anything else
a) We'll try it this way and see if it works.
26) Well it is the policy, and it should be done this way unless a better way is determined. Since things aren't getting done the current way, and it isn't the way the policy is written, you need to do it the way the policy is written. Does that make sense
a) Kind of, but there are too many rules and it doesn't allow us to make decisions on the claims that we are working.
27) I appreciate that, but each person needs to prioritize their day to get the 200 claims out per month and to make sure they work the large dollar accounts in the order the policy says. If you have any questions on the priority, please ask your supervisor before you deviate from the policy. This is really important to the company that we get this done. Its how the company makes money and pays the bills.
All of a sudden I feel like one of the Bobs. I changed my mind, this part of the job sucks.