The Organizational Change Initiative : A More Efficient, Streamlined Overpayment Medical

The Organizational Change Initiative : A More Efficient, Streamlined Overpayment Medical

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The organizational change initiative is to create a more efficient, streamlined overpayment medical claim recoupment process. Currently the organization pays upfront the medical claim without thoroughly examining if the claim is valid. Therefore, the overpayments of claims occur due to changes in a member’s eligibility and/or manual processing errors of the diagnosis codes. In order to recoup the overpayment, a written recoupment request must be made within 365 days of the paid claim. After the initial letter is sent, if payment was not received a series of letters are sent to the debtor at 30, 60, 90, and 120 days. No other contact is made to the debtor. After 120 days if no payment is received, the debt is either written-off. For hospital and providers the case is forwarded to the Legal department for potential arbitration.
The propose change initiative would require a tuning process. “Most important change initiatives that grow out of existing quality-improvement programs would fall into this category”. (Cawsey, Deszca, & Ingols, 2016, p. 21). Minor process changes would be needed to fine-tune the current workflow. Implementing a stronger systematic approach to claims payment, more-in depth recovery process will allow the internal departments, such as claims payment, claims overpayment, customer service and Legal to align. Overall the desired outcome will reduce the number of medical claims paid incorrectly, as well as increase the amount of money recouped from overpayments.

Change Diagnosis

“Change often requires questioning established organizational beliefs and routines and often replacing them with new beliefs and practices.” (Bourne, 2015, p. 143) Presently, the health insurance pays on the erroneous claim and the a...


... middle of paper ...


...e with appeals and grievances. Once all efforts were exhausted the insurance holder was sent to collections for the overpayment recoupment. For the hospitals and providers, who were delinquent on providing overpayment the legal department reconstructed their contracts incorporating overpayment guidelines. The language assisted with all participating parties acknowledgment on the correct procedures. This included offsetting future claims to recoup the overpayment. If no future claims existed after 60 days, the case would be sent to arbitration.
The final and most important result was reducing the claims paid error, which in turn reduced the overpayments. For the claims that fell through the cracks, the recoupment process would aid in bringing the funds back to the organization. This addressed the increased health care costs and maintained lower premiums for members.

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