Scripps Health Employs Captiva Software To Automate Eligibility Of Benefits Form

Scripps Health is a modern healthcare provider in San Diego, CA with six hospitals, several thousand employees and some of the most modern facilities in the country. The company has come a long way since it was founded in the late 1800's.

While their patient care was second to no one, the company realized that their payment processing system was antiquated. Many things had changed since they opened their first hospital, but the manual processing methods they employed in their central processing office were decidedly old fashioned. Everything was still paper-based and manually key-entered into their mainframe computer.

When Scripps decided to update its central business office two years ago they looked at many different systems. The system they chose needed to be able to handle the 1,500 EOB (eligibility of benefits) forms they received from insurance company's everyday. While the volumes were not immense, there were more than 120 different types of forms that needed to be processed. These vital forms reveal how much Scripps is supposed to reimburse the hospital for services rendered. Accuracy was critical because each form contained detailed payment information about the patient. Since each form had its own quirks, automated processing would be a challenge.

The current manual system was costly, time consuming and labor intensive. After the check passed through the lock-box it was sent to the central processing office where workers manually key-entered the data into Scripps mainframe computer. But entering the data was only part of the process. After the information was safely stored in the computer system, the EOBs had to be manually filed. When somebody wanted to query a claim, the file had to be manually located, pulled off the shelf, copied if necessary and refiled.

"The system didn't work," said Wayne Gill, EDI manager for Scripps, "the potential for errors existed. Information was sometimes misfiled, mislaid or not available because someone was using that file. This often could result in a lengthy search," said Gill.

While manual data entry was costly, and filing inefficient, the real costs became evident when serving claims. Having employees search file rooms containing hundreds of thousands of paper files, or going from office to office to find a particular file was costly and inefficient. Realizing that there had to be a better way, Scripps started looking at alternatives. They wanted a system that would grow as they grew and change as their business changed. It also needed to be cost effective, easy to use and enhance employee job satisfaction. "We wanted to do more than automate our manual systems," says Gill. "We wanted to change the way we did business."

Scripps chose Captiva's solution because it not only met Scripps' needs, but it was cost-effective, relatively easy to learn, could handle many types of forms, and the information was available to employees shortly after scanning.

"Now when a hard copy EOB comes in, it goes through the lock-box and then comes to us. We scan everything, then edit the forms. During editing the forms are indexed and stored in an optical jukebox for immediate retrieval," said Gill.

As staff edit and index the forms, payment information is extracted from the EOB and stored as a file. At the end of the day, this information runs through a translation package and the data is reformatted for the payment system and posted as a batch that night.

Staff retrieve data by account number or patient name, and a note is placed on the record in the mainframe alerting users that an image is available. The productivity benefits are enormous because staff no longer have to go to the file room or search desks to find the information.

Scripps is also using Captiva's workflow module to route work to employees based on specific criteria. This includes payee, facility, and amount of work in an employee's electronic inbox. After the employee completes the necessary tasks, the form can be automatically or manually forwarded to the next stage.

"It may need to go to a supervisor because there is something unusual with the payment or because the employee wants to check something. While everything can be processed electronically, people still want the security of paper. At the moment we are still storing the original paper, but eventually we plan to discard it," said Gill.

"The Captiva system is great. We fully account for all paper coming into the central office because everything is scanned. Our staff can quickly view and print whatever they need and no longer have to spend hours searching for data. It has cut out the hack work and allowed employees to focus on their jobs."

"At the moment we are working with Captiva to expand the system. Our next step will be to bypass the scanning stage and load the electronic files some payees give us to create electronic images."