Projects & Results

The members and adopters of the Washington Healthcare Forum's Administrative Simplification Effort have implemented twenty-three (23) policies and guidelines through their collaborative work. Pilot studies were preformed to demonstrate the time savings that can be achieved through implementation by additional members of the hospital and provider communities.

Policies:

Claims Processing

1. Submitting Supporting Documentation
   • Hospital Staff: 1 hour per week
   • Provider Office Staff: 1 hour per week
     
     
2. Submitting Corrected Claims
   • Hospital Staff: 1 hour per week
   • Provider Office Staff: 1 hour per week
     
     
3. Follow-Up on Processed Claims
   • Connect with the right person the first time
   • Quicker resolution of questions on processed claims
     
     
4. Using Common Modifiers
   • Provider Office Staff: 1 hour per week
     
     
5. Anesthesia Standards
   • Anesthesia Office Staff: 1 hour per week
     
     
6. Claims Receipt & Processing Standards
   • Hospital Staff: 2 hours per week
   • Provider Office Staff: 1 hour per week
     
     
7. Reasons for Splitting Claims
   • Fewer split claims occurrences
   • Time savings for facilities and providers who reconcile split claims
     
     
8. Handling Injury Claims
   • Hospital Staff: 6 hours per week
   • Provider Office Staff: 4 hours per week
     
     
9. No Paper EOBs
   • Hospital Staff: 5 hours per week
   • Provider Office Staff: 4 hours per week
     
     
10. Resubmission of Electronic Claims
    • Hospital Staff: 1 hour per week
    • Provider Office Staff: 1 hour per week
      
      
11. No Clinical Notes with ER Claims
    • Hospital Staff: 10 hours per week
      
      
12. Patient Insurance Card Not Required
    • Hospital Staff: 3 hours per week
    • Provider Office Staff: 3 hours per week
      
      
13. Adjustments Made to Paid Claims
    • Clarity on how different plans handle claims adjustment

 

Referral & Prospective Review

1. One-Stop-Shop Processing Requirements
   • Hospital Staff: 12 hours per week
   • Provider Office Staff: 3 hours per week
     
     
2. Standard Referral Actions
   • Hospital Staff: 1.5 hours per week
   • Provider Office Staff: 1.5 hours per week
     
     
3. Self Referrals for Women's Healthcare
   • Better access to care for Women
   • Fewer denied claims and calls to health plans for self referring Women
     
     
4. Numeric Billing Codes on Referrals & Authorizations
   • Hospital Staff: 1.5 hours per week
   • Provider Office Staff: 1.5 hours per week
     
     
5. Tolerance Days for Referrals
   • Provider Office Staff: 2.5 hours per week
     
     
6. No Referrals to Hospital Emergency Rooms
   • Hospital Staff: 1 hours per week
   • Provider Office Staff: 1 hours per week
     
     
7. Requesting a Prospective Medical Clinical Review
   • Hospital Staff: 1 hours per week
   • Provider Office Staff: 1 hours per week

 

Credentialing

1. Credentialing Handbook
   • Clear expectations and communication between new providers, groups and health plans
     
     
2. Confirmation of Receipt of Credentialing Application
   • Avoidance of credentialing delays due to incomplete applications
   • Better understanding of the credentialing process and its timeframes
     
     
3. Adjudicating Claims as of Credentialing Effective Date
   • Clear expectations and communication between new providers, groups and health plan