Read the DocSystems Billing case, including the briefing document and four scenes, and consider the following questions:
Briefing Document: DocSystems Billing, Inc.
DocSystems Billing, Inc., processes insurance billing paperwork for a network of small health care clinics throughout the United States. Privately owned physician practices, as well as specialists such as cardiologists and physical therapists, contract with DocSystems to process the billing paperwork through the maze of health care insurance companies and networks. DocSystems charges either a flat fee for each bill it processes or a percentage of the total, depending on the contract with the provider.
The remaining group of 40 employees was reorganized into two new teams about 3 months ago. Initially, there had been two managers—Alex managed the senior insurance consultants, and Dana managed the medical insurance specialists. Both reported to Jim, the senior director. In the new structure, Alex and Dana both manage 20 employees, with each managing half of the specialists and half of the consultants.
That meant that some of each group remained with their former manager, while some moved to a new manager. Senior management hoped that the integrated teams would start to share knowledge between more senior and more junior practitioners.
The billing specialists do the initial computer input and handle the majority of the cases. Normally this occurs without any need for DocSystems intervention or assistance, but occasionally there are difficult issues that arise. For example, a cardiologist may have conducted a certain procedure that fits more than one category in the DocSystems database, and the billing specialist may be unsure how to categorize it accurately. A phone tree system has been set up between the outsourced organization and DocSystems so that the billing specialist can call any of the medical insurance specialists, who are required to be on call at least 4 to 5 hours during a typical 8-hour shift. The partners can also formally escalate cases by handing them off through the system for a medical insurance specialist to work.
A similar process works for the medical insurance specialists. They are assigned insurance cases on a round-robin basis. They typically handle two types of cases: (1) any case that has been “kicked back” by the insurance companies for more information and (2) any case where the patient has filed a complaint, grievance, or appeal. Like the billing specialists, they work on the case to get it accurately processed and filed, and if they run into problems, they can call on their senior counterparts, the senior insurance consultants, to ask a question. They also have the opportunity to formally escalate cases to have one of the senior insurance consultants handle the case if it seems too complicated.
The senior insurance consultants handle anything and everything, but they usually work on only the most complex cases. They also answer questions from the medical insurance specialists. They usually get their work from formally escalated cases that the medical insurance specialists cannot handle on their own.
Dave and Jim sit at a large oval table in Jim’s office, discussing the OD engagement and plans for the upcoming team meeting.
Jim: Thanks for meeting with me. I really need your help facilitating this team meeting.
Dave: No problem, I’m glad to help. Maybe you can start by telling me what you’re trying to accomplish.
Jim: Basically we’re trying to redesign how the call center works. We have a few problems. The first problem relates to processing times. Our physician clients obviously want their payments as quickly as possible, so the billing specialists must work very rapidly to input the payment request to the insurance company. Also, our physicians want us to service their patient problems and appeals very quickly. Each role in the process is critical to getting the work done and processed as quickly as possible. Time is our number one success metric, and it’s our number one failure right now.
Dave: What are the results today?
Jim: Right now we only have about 80 percent of our customers that say that they’re satisfied with our services. From what I’ve read in our industry, that’s at the very bottom. We’re seriously in danger of losing customers if we can’t speed up.
Dave: Have you done any analysis of where the bottlenecks might be occurring?
Jim: Yes. First, you should realize that the workload is tremendous. Each week, the billing specialists handle almost 2,000 claims in total. Our medical insurance specialists handle about 50 cases each per week, and the senior consultants about 10. It might not seem like a lot to handle only 10 or 50 cases per week, but some of the more complex cases can take 2 to 4 hours each to process. If we can’t meet our time commitments, our clients and patients get frustrated. So we have metrics in place to monitor how well it’s going. If a case takes more than 4 hours to process, it turns “red,” which means that in our automated system, the case shows up on our urgent list. When a case turns red, we know from past data that it represents a customer who is dissatisfied, or it doesn’t meet our service levels. The more red cases, the more likely we are to lose a customer or to lose money because we have to reimburse our clients when we don’t meet our agreements with them.287
Dave: What about the outsourcing? Do you have contractual agreements with them on their own processing timelines?
Jim: Yes, and actually they’re doing pretty well. We don’t usually have too many problems with them. The real problem comes when the cases get escalated to us. We have far fewer cases to handle, yet since they’re complex they tend to take longer. Some of our physicians have special service contracts with us where their requests and their patients get top priority. They pay extra for the service, and they expect higher service from us as a result. For our Platinum Tier physicians, we have an agreement that we will get back to them with a resolution to their problem within 2 to 3 hours.
Dave: What is the cycle time today?
Jim: It’s 15 hours at the moment. In other words, they expect a resolution in less than half a day, and we get them an answer in 2 days.
Dave: What do you think is causing the delay?
Jim: First, the cases are remaining with the medical insurance specialists for too long. Their cases turn red at a faster rate than anyone else’s. It’s the volume that’s killing us. Each of them is forced to juggle 10 to 20 cases at a time. It’s too much for them to take on, in addition to the calls that keep coming to them from the billing specialists.
Dave: Why don’t they escalate to the senior insurance consultants?
Jim: They do, sometimes. But once they’ve started to work it, I guess they think they may as well finish it. We just need to hire more people, but we can’t afford it right now.
Dave: Do you have any ideas about what could solve this problem?
Jim: Yes, and that’s in part the reason I called to get your help. I want the 10 senior consultants, who are the most knowledgeable, to help the 30 medical insurance specialists with their caseloads. We want more collaboration on the teams. That’s why I’ve scheduled the 2-day meeting that we talked about, and I’d like your help facilitating the team through a design session where we get their input and figure out how this new collaboration process will work.
Dave: I’m definitely willing to help facilitate the session, and I believe it’s the right approach to involve them in the design. First, though, I think it would help me to understand their work better if I could see how they worked. Do you think that one of the medical specialists and one of the senior consultants would let me observe them for a few hours?
Jim: I’m sure they wouldn’t mind at all. You should meet with Rosie and Carlos, who are our top performers. I’ll send them an e-mail and ask if it would be okay if you contacted them and set up a time to talk. Rosie and Carlos will also be on our project design team, so it will be good for you to get to know them now.
Rosie Jones, a medical insurance specialist, looks up as Dave approaches her desk.
Dave: Hi, Rosie. I’m Dave.
Rosie: Nice to meet you. Please have a seat. I hope I can help you with your questions.
Dave: I appreciate you letting me observe. As I said when we arranged this, I really don’t want to take up too much of your time. I’m just interested in learning more about what you do so we can figure out this project together. What are these monitors for?
[Dave points to the three computer monitors all located side by side on Rosie’s desk.]
Rosie: This one is for my e-mail, this one is for the case database, and this one shows the calls that are currently waiting on hold.
Dave: And the one with the case database—what are the numbers and colors?
[Dave notices that the screen is full of line after line of case numbers, patient names, and insurance company names. About half are black and about half are red. More than 30 cases are listed on the screen.]
Rosie: These are all of my open cases. The numbers represent the case numbers, and the red type means that the case is behind. This last column shows the status. So if you look, most of them either say “Waiting Patient” or “Waiting Physician.” On those, I’m waiting for a return call. Some I could just close out now. So at the moment, there’s not much I can do. Well, I guess on these last three I could get started on them. Let’s see what they say.
[Rosie clicks on the screen and opens up one of the red cases.]
Rosie: This one says DED-1, which means “Denied for patient status.” I’m not sure what happened, but it looks like we may have sent the case to the wrong insurance company, who denied the case and sent it back to us. This patient also has two health insurance companies to deal with. I’m going to have to call the physician.
[Dave looks at the screens, mesmerized by the amount of detail there is to monitor. Rosie is typing and clicking so quickly, Dave can’t follow. Rosie marks the current case “Waiting Physician.”]
Dave: It certainly seems that there’s a lot going on at any one time. How often do you escalate cases?
Rosie: [looks up quickly and stares at Dave] I don’t really need to. I know how to do my job. These are my cases, and I want to work them. Besides, we all know what happened to the billing specialists when they got outsourced. You think I want to give up my work and not be doing anything?
Dave: What do you think about the model that Jim is talking about, where the senior consultants would jump in and help out with your caseload when it’s too much?
Rosie: [forcefully] You mean Big Brother watching over me?
Later that same day, Dave arrives at his appointment with Carlos Chavez, a senior insurance consultant.
Dave: Thanks for letting me sit with you for a bit. How long have you been with DocSystems?
Carlos: [pouring a cup of coffee] It will be 19 years next month. I’ve done it all, from billing, to insurance, to management. I remember when we used to have only three insurance companies to deal with, and I knew the physicians personally. Now there are so many clients, patients, and insurance companies, it’s really amazing.
[Carlos adds sugar and cream to his cup and they return to his desk, just a row of cubicles away from Rosie’s. Like Rosie, Carlos has three monitors arranged in a semicircle on his desk, each showing the same information that Dave saw on Rosie’s monitors.]
Dave: What kinds of cases do you tend to work on?289
Carlos: Well, here’s my list right now.
[Carlos points to the case monitor. There are just three cases showing, all listed in red.]
Carlos: I have this one, which was escalated because the patient was so upset. She had three different physicians she was working with, and only two were part of our client list. The insurance company got confused and ended up paying too much, but we also ended up mistakenly billing the patient for the work of one of the physicians. You can see the case notes are three screens long.
[Carlos scrolls through the case record showing the extensive list of comments.]
Dave: Looks like there is indeed a lot to sort through. How many of these do you work at a time?
Carlos: [putting his feet up on his desk] Ah, it’s not that bad. This is pretty typical, with about one new case per day. It will take a few hours to sort through, but mostly it’s manageable, isn’t it, Michelle?
[Carlos yells over his cubicle wall to a neighbor. Michelle stands up and introduces herself to Dave as a senior insurance consultant.]
Carlos: Michelle and I both left Alex’s team to work for Dana. Well, I supposed we were technically forced to work for Dana. [They laugh.]
Michelle: Yeah, that’s been a joy, hasn’t it? If at first you don’t succeed, reorganize to make sure you won’t.
Carlos: [turning to Dave, voice rising] You know, we were put into our new team 3 months ago. Dana just had our first staff meeting on Thursday last week. She hadn’t even called us to welcome us to her team.
[Michelle pulls out a sheet of paper filled with tally marks. At the top it reads, “Where’s Dana?” There is a cartoon drawing of a person on top of a mountain with “Dana” written above it, and 15 stick figures at the bottom of the mountain with question marks over their heads.]
Dave: So until last week, you hadn’t even spoken to your new manager?
Carlos: Whatever. It was much better on Alex’s team, but hey, I figure the pay’s the same whether I leave at 5:00 or 6:30, whether I have 3 cases or 30. We’ve had the standard 2 percent raise for the past 3 years, and it won’t be any different this year.
Dave: What do you think about the model that Jim has proposed to the design team, where the senior consultants would help out on the medical insurance specialist caseload?
Carlos: I guess I understand where he’s coming from. But I don’t want to sit on the phone all day dealing with the same old patient status issues. Been there, done that. And I’m not about to take over the caseload for a lazy med specialist who just waits until the case gets old enough for me to work it for them.
It’s 8:30 on Wednesday morning. Jim begins the design session meeting with a kickoff presentation. In attendance are Dave, Rosie, Carlos, and Alex (the manager of one of the call center groups).
Jim: I really appreciate everyone taking time out of their schedules to work on this program. I’m confident that we can come up with a good solution. You’re among our top performers in the division, and you know best what will work and what won’t work in our company.
Jim spends the first few hours of the meeting reviewing the importance of the call cycle times, showing the group charts with the data he has collected: customer satisfaction numbers (last year, year to date, last month), call answering times (in minutes, listed by month for the past 12 months), case volumes (number of new cases opened, number of cases closed for the past 12 months), and number of red cases (by month).
Next, Dave facilitates the group through an approach that Jim has suggested all along, where the senior insurance consultants would collaborate on cases with medical insurance specialists. In the new process, senior consultants would have a new job task of monitoring the current list of red cases and pulling them from the medical insurance specialists if they felt that they could work the case faster based on their knowledge and experience. The new process would require that all senior consultants monitor the list regularly and read through any new red cases.
Dave notes to himself that neither Rosie nor Carlos raised the objections they had shared with him privately, but instead both seem very energetic and willing to experiment with some changes. With confidence high, the group takes a lunch break. After lunch, Dave checks the agreement the team appears to have reached.
Dave: So, Carlos, what do you think of the solution we’re proposing?
Carlos: It will never work.
Carlos: I don’t know. I can just tell you right now, this will never work.
[The group looks silently at Dave.]
Dave: You seemed more confident this morning. What changed your mind?
Carlos: I was out at lunch talking with Michelle and a couple of other people on Dana’s team. They hate the idea and think it’s just more work for us, and a way for the medical insurance specialists to pawn off their tough cases. I mean, no offense to Rosie, she handles her own cases well. But why should we jump in? We have our own work to do. People are basically lazy, and unless you force them to work on the new cases, they aren’t going to volunteer.
After an hour of discussion, the group makes little progress. The morning’s agreement has dissolved. With only a few hours to go in the meeting, the attendees begin to abandon hope that they could reach a solution, and Jim intervenes.
Jim: Look, here’s what I propose. Let’s call it a day for now, and we can reconvene next week to talk about it more. Thanks for your input, everyone, I know that we can handle this. It’s a tough situation but I appreciate your participation on this project. Dave, can you hang around for a few minutes?
[The group walks out quietly as Dave begins to stack up some of his papers.]
Jim: [shaking his head] I really thought we were headed toward a solution. [raising his voice] Why can’t people just say what they think if they have a problem? Why did we have to go through all of this?
Dave: I know that you’re frustrated, and I’m getting a bit frustrated myself. Clearly the team is frustrated. But I also have to remember that it’s better that we find out their objections now rather than a month from now when we’re wondering why the new model isn’t working.
Jim: I’m at a loss. What do we do now?
Dave: I’ve listened carefully to the team today, and I’m also thinking about my meetings with Rosie and Carlos. I’m also thinking about the structure of the work and of the two teams at this point. Let’s plan to meet at 8 on Friday morning. I’ll prepare my thoughts about what I’ve heard so far and what I think we should do next.
Jim: Friday at 8 works for me. I’m anxious to get your perspective.