Reimbursement Unit

% of claims that were originally submitted in a timely manner but were denied payment (timely filing) turned around in 15 business days or less

100.0%Aug 2020

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Partners
  • Medicaid Providers
  • DXC
  • Department of Mental Health
  • Department of Aging & Independent Living
  • Department for Children & Families
Story Behind the Curve

Medicaid has regulations on how long providers have to submit claims for reimbursement, this is called timely filling. For claims originally submitted in a timely manner but denied payment, the DVHA Reimbursement Unit will review for payment. This performance measure will track how long the Reimbursement Unit takes to review denied claims and make a final decision on whether or not to pay them.    

This measure is important to ensure that provider reviews of timely filings are processed in a consistent and timely manner. Providers will appreciate having a decision sooner rather than later.

The August 2019 target was not met due to a competing project that was prioritized for the individual devoted to working timely filing requests. 

An important factor in meeting the unit’s target each month is consistency in the flow of and volume of requests received.  During the period of June to December 2019, the volume of requests increased an average of 146% compared to the same period of 2018. The per month increases ranged from a low of 10% to a high of 394%. The increase in volume can reasonably be attributed to the issuance of updated timely filing guidelines in February 2019.  It had been many years since the last update.

In addition to an increase in volume, or perhaps because of it, DXC informed the unit in October 2019 that they were experiencing a delay in forwarding requests.  Over the next 3 weeks DXC uploaded the backlog of requests in large batches while continuing to upload the ongoing requests being received. As a result, the unit has been unable to meet its monthly target of completing 80% of requests received in 15 business days. The unit is continuing to diligently work through the backlog in addition to the ongoing normal flow of requests being received. We anticipated it will take many months to get caught up.

By March of 2020 the backlog was completed along with the normal monthly flow of requests resulting in the unit meeting its target goal.

 

Last updated:  10/15/2020

Strategy

The Reimbursement Unit recently worked with DXC to update the Timely Filing process. Prior to the update, the process was entirely manual with claims handed off in person from DXC to DVHA Reimbursement staff to work the timely filing request and then return to DXC for MMIS processing, if approved for payment. No tracking system was in place so it was difficult and time consuming to determine where a claim was in the process when a provider called for a status update. With the Reimbursement Unit's move to the Waterbury complex the process became even more difficult and lengthier. Claims now had to be transported between Williston and Waterbury by currier, adding an additional 3 to 6 days on each end to the time it took to determine whether to pay the claim(s) or not. 

The Reimbursement Unit, recognizing the process was inefficient and cumbersome, started working with DXC staff to update and streamline the process. Starting in June 2017, scanned documentation replaced the need for a currier and a tracking spreadsheet is now available in SharePoint that is continually updated and viewable by both DXC and Reimbursement. The electronic process tracks the timely filing request from the day it arrives at DXC to the day a final determination is made by Reimbursement and communicated to DXC.

Now that a tracking system is in place, the Reimbursement Unit has set a goal to review and make a payment determination on 80% of timely filing requests within 15 business days of being received in the unit. There are various challenges to achieving this goal such as:

  • The free flow of requests in a timely manner to the unit
  • The appropriateness of documentation included in the request (i.e. does it support the providers claim or is additional support needed to make a determination)
  • Complexity of the case
  • For timely filing requests received that require a determination by a sister department, receiving the determination in a timely manner
  • Obtaining management approval, when appropriate
  • Working out the "bugs" of a new process.
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