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HEALTH CARE FINANCING ADMINISTRATION 



CARRIER WORKLOAD 
AND PROCESSING TIME 



REPORT 
JANUARY 1986 




REPORTS 

RA 

2 , 

367 

Q86:Jan. 



t VS. Department of 
! Health and Human Services 
r Health Care Financing Administration 
Bureau of Quality Control 



f 



C 



Ml 

FOREWORD 



This report summarizes the status of claim workloads reported by carriers 
for January 1986. Presented in this report are national summary tables and 
carrier detail tables showing the numbers of claims received, processed, 
and pending.' Also included in this report are data on electronic media 
claims, claims processing times, and the percentage distributions of 
processing times and pending claims. Definitions of terms used in the 
report are given in the Appendix. 



Comments, suggestions, and/or questions relative to this report should be 
directed to: 

Health Care Financing Administration 

Office of Program Quality Evaluation, BQC 

Division of Reports and Analysis 

239 East High Rise 

6325 Security Boulevard 

Baltimore, MD 21207 

(301) 597-1880 



c 



* 



CARRIER WORKLOADS AND PROCESSING TIMES 



JANUARY 1986 
HIGHLIGHTS 



January 1986 

Percent Percent 
January December January Chg from Chg from 
1986 1985 1985 Dec 1985 Jan 1985 



Number of 

Claims Received 25.84 24.05 23.78 7.5 8.7 

Claims Processed 24.51 22.71 23.05 7.9 6.3 

Claims Pending 13.70 12.38 11.04 10.7 24.1 

Net Assignment Rate 67.6 68.2 66.4 -0.9 1.8 

Electronic Media Claims 

Number 6.03 5.46 4.02 10.4 49.9 

Percent Received 23.3 22.7 16.9 2.6 37.9 

Mean Processing Time (Days) 17.3 15.3 16.5 13.1 4.8 

Inquiries Processed 

Total 1.79 1.50 NA 19.1 

Per 1,000 Claims Received 69 62 NA 11.3 

Beneficiary 1.33 1.09 NA 21.2 

Per 1,000 Claims Received 51 45 NA 13.3 

Provider 0.46 0.41 NA 13.4 

Per 1,000 Claims Received 18 17 NA 5.9 

Medicaid Crossover Claims 

Number Transferred to States 2.43 2.23 NA 8.7 

Transferred via EMC 1.70 1.54 NA 10.2 

Percent Transferred via EMC 70.0 69.1 NA 1.3 



NOTE: Numbers in millions 
NA- Not available 



o In January 1986, carrier receipts rose to 25.8 million claims, an 
increase of 8.7 percent over the 23.8 million claims received in 
January 1985. 

o The net assignment rate increased 1.8 percent, rising from 66.4 
to 67.6 percent over this period. 

o The percent of claims received via electronic media increased 
37.9 percent, rising from 16.9 percent in January 1985 to 23.3 
percent in January 1986. 

o The number of claims processed, 23.1 million in January 1985, rose 6.3 
percent, to 24.5 million in January 1986. 

o For all HCFA-1500s, the average processing time rose 4.8 percent — 
from 16.5 days in January 1985 to 17.3 days in January 1986. 

o Total claims pending rose from 11.0 million in January 1985 

to 13.7 million in January 1986, an increase of 24.1 percent. 

+ During this period, claims pending over 30 days increased 28.7 
percent (from 1.4 to 1.8 million). 

+ Claims pending over 60 days (455,000 in January 1985) increased 
45.4 percent, rising to 661,000 claims in January 1986. 

o Both the number of inquiries and the ratio of inquiries processed 

per 1,000 claims received showed an increase in January 1986 compared 
to the previous month. 

+ The ratio increased 13.3 percent for beneficiary inquiries and 

5.9 percent for provider inquiries — an increase of 11.3 percent 
overall from December 1985. 

o Medicaid crossover claims transferred to State Agencies or their 
fiscal agents increased 8.7 percent, from 2.2 million in December 
1985 to 2.4 million in January 1986. 

+ Gaining 1.3 percent (from December 1985 to January 1986), the 

percent transferred via electronic media rose from 69.1 to 70.0 
percent . 

Division of Reports and Analysis 



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CARRIER WORKLOAD AND PROCESSING TIME REPORT 



APPENDIX 

Off iD±tion^_of _Terms_Used 

Claim — - A writing, identifying or permitting the identification of an 
enrol ie© , which requests reimbursement for what appears to be medical or 
other health services furnished by a physician or supplier. There are a 
number of situations where a claim is split into one or more additional • 
claims — see instructions contained in Section 3000 of the Medicar e_ 
Carr iers_Manual . 

Repl icate_Claims--Claims split for reasons other than those identified in 
Section 3000 of the Medicare Carriers Manual are defined as replicate 
claims. Some examples of replicate claims are claims created because of a 
computer line item limitation, claims created in making partial payments, 
and claims created for carving out Individual specialty types of services. 
Unless otherwise noted, information shown in this report reflects data for 
all claims, including replicates, handled by carriers. 



§j 1§_R?9§ A ved Dur i ng_Month — The net number of claims received. (Gross 
claim receipts minus transfers to other carriers.) 

Ql§ims_Pr^ce^se^_p^r^n^_M^nth 

A. Total — The sum of claims paid, claims applied to the deductible, and 
claims denied. 

B. Rat io_of _Prgcessed_to_Recei ved — (The total number of claims processed 
divided by the net number of claims received) times 100. 

C . Paid-- Includes all claims processed for which some payment was approved 
and an E0MB prepared. 

D . Appl ied_Toward_Deduct ible — Claims for which no payment was made because 
the deductible was not met. 

E. Denied — Claims denied in full for any reason. 

F. Mumber _Excl uding _ Rep li gates — The total number of claims processed minus 
the number of replicate claims processed. (See above for definition of 
a replicate claim.) 



21 



A. Number~-The total number of claim® pending at th® and of tha month. 

E . Dax§_Wgrk_on__H§nd«— Claiaa pending and of month times tha number of 
working daya summed for aoat racent 12 aontha dividad by tha nuobtr 
of claiaa proceaaed auaaad for aoat racant 12 aontha. 

C. Day,a_Work_on_Hand_0var_30_Da XS # — Claiaa pending ovar 30 daya at and of 
aonth tiaaa tha number of working daya auaaed for aoat recent 12 aontha 
divided by the number of claiaa proceaaed summed for moat recent 12 
aontha . 

D« 5§y§_y2^ ^5_20_M§0^_QY®? _§2_0l§X® *~™ l C^ a ^ 3RS pending over 60 daya at end of 
month timee the number of working daya aummed for moat recent 12 montha 
divided by the number of claima proceaaed aummed for moat recent 12 
montha . 

«N0TE: Suapended claima are excluded from counta of claima processed and 
pending in items B, C, and D above. Suapended claima are claims suspended 
from procesaing due to HCFA directivea. Such claims are usually thoae 
submitted by physiciana or auppliera under investigation for queationable 

utilization or billing practices. 

^®^_^§§i2D5§0^_8St? — (Assigned HCFA-lSOOs received divided by the sum of 
assigned and unaasigned 1500a received) timea 100. 

A ° HHE2§E""" 7n ® total number of electronic media claima (EMC) received 
(i.e., via magnetic tape or telecommunications device). 

8 . Percent^of _Tgtal_Received — -(The total number of EMC received divided by 
net receipta) timea 100. 

C. Percent_gf„Assigned_HCFA-li9Qs_^ — (Assigned HCFA-1500 EMC 
receipts divided by total assigned HCFA-1500 receipta) times 100. 

D * P®E£®0^_2C-y055§iS0f d_HCFA-1500s_§eceived-- (Unaasigned HCFA-1500 EMC 
receipta divided by total unaaaigned HCFA-1500 receipta) timea 100. 

5S Bii2§t®_5ISi*§_iESi;2SDt_2C_X2^Sl«EE2SS§§®dl""'" c ' rh * number of replicate 
claima processed divided by the total number of claima processed) times 

100. 

Claiaa_Inye §iiSI^i2S„S§^f ~~ (Th® number of claims investigated divided by 
the total number of claims processed) times 100. 



22 



Clail§_Pl2£§§Sf d i _Average_Prgcessing_Ti»2 A _an 

ft. Number — The tun of claima paid, dales applied to the deductible, and 
claima denied ainua proceaaed claiia prevloualy auapended due to HCFA 
directivea. 

B . Mean_(Average^_Procea5ing_Ti»e — The arithmetic aean proceaaing 
time for all typea of HCFA-1500 claima. The overall aean ia obtained by 
weighting the aeana by type of claim by the number of claima by type of 
claim. Claima proceaaing time is defined aa the length of time in 
calendar daya from the date of initial receipt of the original claim to 

4 the date the EOMB or denial letter ia prepared. In Instances where 
carrlera make periodic "roll-up" payments, claima are conaidered 
proceased when the completely adjudicated claima are posted to a 
aummary payment tape. Hating or file (see Medicare_Carrier_Manual 14-3 
Section 13321.2). 

C . Percentage_Diatr ibution — Diatrlbution by daya required to process. The 
percent of claima proceaaed within a time frame la determined in the 
following manner. The number of claima reported as processed within the 
specific time frame la divided by the total number of claima reported 
as proceased (excluding those suspended) during the month by the 

I carrier and then multiplied by 100. 

I. Number — The total number of claima pending (received and not proceaaed 
to completion) at the end of the month leaa pending claima auapended 
due to HCFA directivea. 

i . Percentage_Distr ibution — Diatrlbution by daya elapaed aince receipt. 
[ngulriea_Proceaaed 

^* l2tal_Number — The total number of inquirlea proceaaed, by type of 
inquiry (telephone, walk-in, written) . 

i*DSil9i§£Y_lD9yiEiSS — The number of proceaaed inquirlea from 
beneficiaries, by type of inquiry. 

Z . Provider_Inguiries — The number of processed Inquiries from providers, 
by type of inquiry. 

I. Ratio_of_ I nguiriea_ Processed^ — (The number of 
each type~of inquiry proceaaed divided by the net number of claima 
received) timea 1,000.* 

i *NQTE : Thia formula appliea respectively to All Inquiries, Beneficiary 
' Inquirlea, and Provider Inquirlea, and, within each of theae 
categories, to telephone, walk-in, and written inquiries. 



23 



CMS LIBRARY 




3 60^5 00014H3B E 



Medicaid_Crg§gov§ r_Clai»s 

*• Num^er_Tran§£ erred — The total number of Medicaid croaaover claiaa 
tranaf erred to State Agenciea or their fiscal agenta. 

B. Number_of _Electronic_Media_Claiaa — The total number of Medicaid 
croaaover claiaa tranaf erred via electronic aedia. 

C. Percentof _Total _Tranaf erred — (The total number of Medicaid croaaover 
claima tranaferred via electronic media divided by the total number of 
Medicaid croaaover claima tranaferred) timea 100. 



&U.S. GOVERNMENT PRINTING OFFICE:! 98G 9 U 2 6 i(/ it 2 3 6 



24