Trigon HealthCare

Trigon Healthcare, Inc. is the independent licensee of the Blue Cross Blue Shield Association for Virginia. Established in 1935, Trigon became a public company in early 1997. With a 31% market share in its licensed service area, Trigon Blue Cross Blue Shield is the largest health care insurance company in Virginia , with nearly 4,000 employees serving approximately 1.8 million customers through a wide variety of regional and statewide networks. Trigon is ranked by industry analyst Booz, Allen & Hamilton Inc. among the top Blue Cross Blue Shield organizations in America - a clear sign of its strength.

Trigon offers a range of more than 15 health care plans. In Virginia, Trigon serves health care needs as diverse as the state itself. Company sponsored plans comprise approximately 80 percent of their business: Trigon covers students; individuals such as those who are self-employed, between jobs, or retired; state and federal workers; and employees of small businesses, regional companies, and major corporations. Some Trigon HMO subsidiaries also offer Medicaid HMO products to qualified individuals, and will soon introduce a new Medicare HMO product. Beyond the borders of Virginia, Trigon's related businesses offer expertise in third party claims administration for medical and workers' compensation, health and wellness programs, and insurance services in 25 states and the District of Columbia.

Continuous improvement - from the products they offer, to the service they provide, to the care their members receive - is one of the highest corporate goals of Trigon.

THE PROBLEM
Trigon Healthcare receives and processes up to 50,000 paper health insurance claims per day, including HCFA-1500, HCFA-1500 with attachments, UB-92, and dental claim forms. In 1992, Trigon purchased an imaging and workflow system from Sigma Imaging (now owned by Eastman Software). The implementation won a GIGA Award for Excellence, and Trigon proved to be a successful pioneer in what is now a rapidly expanding field of imaging automation.

The claims data capture process, however, was performed separately from the Eastman system, using a mix of REI XP-80/Tartan OCR claims capture system, data entry from paper, data entry from image, and outsourcing. Accuracy of claims data capture was uneven, and the pay rate was lower than that from the EDI stream.

Claims were sorted in the mailroom, and those that could be processed by the XP-80 were scanned into that system. Those successfully processed were then scanned again using one of the four Kodak 923 scanners used in the Eastman imaging and workflow system. Those that could not be processed by the XP-80 system - approximately two-thirds of all claims received - would still be scanned into the Eastman system. These claims would then be data entered through a mixture of key entry from paper, key entry from image, and outside service bureaus. Data entry productivity was less than 150 claims per hour per operator in the XP-80 system, and less than 50 claims per hour per operator in the alternate keying environments. Using multiple approaches for claim capture was unreliable, proprietary, and inefficient, creating a cumbersome and expensive process that was in dire need of improvement. Finally, Trigon's contract to provide health insurance coverage to state employees requires a three-day turnaround for the claim to be entered into the claims processing system, adding incentive to further automate the process.

THE SOLUTION
In late 1995, Trigon hired IMERGE, a prominent imaging consulting firm, to run a national procurement for an automated claims processing system that could tie directly into their existing Eastman imaging and workflow environment. After careful consideration, Trigon selected RRI to provide a ClaimWorks solution.

ClaimWorks is an image-based solution for automating the claims data capture process. Employing advanced OCR and other pattern recognition technology, as well as ergonomic interfaces, extensive reporting, and high performance workflow, ClaimWorks provided Trigon with just the solution it was looking for.

Mr. Richard Womble, Technical Manager for the replacement project, says the decision was not difficult. "The new ClaimWorks system is much more accurate, far more efficient, and has proven to be a rock-solid solution to our needs."

THE BOTTOM LINE
Overall, the ClaimWorks system increased accuracy, efficiency, and reliability of the claim capture process at Trigon.

Louis Rolan, Data Entry Manager for Trigon says, "One of the real ClaimWorks benefits has been the increase in accuracy. We're experiencing better than 99% accuracy - much better than with our old systems." This increase has resulted in fewer claims that pend, and fewer errors in payment.

The increased efficiency of ClaimsWorks has lead to a number of key tangible results. Sorting in the mailroom has been reduced from 8 to 3, and all claims are automatically processed in one system. And because ClaimWorks ties directly into the Eastman software system, documents are now scanned only once. Operator productivity jumped from under 150 claims per hour with the XP-80, and under 50 claims per hour from paper and image, to 300 claims per hour overall - the highest of any automated claims processing system. Trigon no longer outsources the data entry of claims now that the cost of internal processing is less than one third the cost of outsourcing. "More than 10% of our claims go through without any operator intervention at all," says Rolan. "The rest go through with minimal intervention."

Reliability has been improved and maintenance costs have been reduced as well. Where Trigon used to have a full time REI technician in their offices, the ClaimWorks system is almost self supporting. "We have experienced 100% up time with the ClaimWorks system. It has required only nominal internal support since installation. " says Womble.

Finally, although only the state contract mandates a turn-around time, Trigon believes all of its customers deserve the same service. With ClaimWorks, and clever management, Trigon has reduced turn-around on all claims from just under three days to just under 1.5 days.

The system has been so successful that Trigon has decided to consolidate the mailroom around ClaimWorks. The Trigon Mail Room Consolidation Project involves coordinating the processing of claims from all programs, as well as other forms such as enrollments. Trigon has nominated ClaimWorks for both a GIGA Award for Excellence and the Smithsonian Innovation Award.

Jackie McCullough, Claims Processing Manager, is particularly pleased with the outcome. "RRI has been an excellent partner for Trigon. The solution has exceeded our expectations, and RRI has been extremely responsive to our needs. We foresee a long relationship with RRI and further benefits from the ClaimWorks solution as we move Trigon to the next level of customer service."