05 Dec Case Study 7: Solving Team Challenges at DocSystems Billing, Inc.

Case Study 7: Solving Team Challenges at DocSystems Billing, Inc.

Read the DocSystems Billing case, including the briefing document and four scenes, and consider the following questions:

1. What problems exist in this organization? How do these problems differ based on the employees’ roles? Why do employees object to Jim’s proposed solution?
2. Make a recommendation to the client about what could be done next based on the data included. Summarize your observations for Jim, offer possible interpretations, and suggest an approach for next steps.

Briefing Document: DocSystems Billing, Inc.

About the Company

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.

About the Call Center

• Forty full-time employees work at the onsite call center: 30 Medical Insurance Specialists (who handle cases of moderate complexity) and 10 Senior Insurance Consultants (who handle very complex cases). The senior consultants have usually worked up through the ranks, often first working on basic billing, then as medical insurance specialists. Most of them have a long tenure with DocSystems, ranging from 17 to 23 years.
• An additional 100 employees (called Billing Specialists) work at an outsourced call center. DocSystems contracts out the initial processing of claims and basic computer input. The contract employees used to work at DocSystems until the outsourcing.285
• The call center was outsourced a year ago to another organization. Almost all of the former DocSystems employees were offered jobs with the new company, but the pay and benefits were not comparable. Word has spread to the former colleagues who remain at DocSystems that the outsourcing company treats its employees poorly.

Call Center Reorganization

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.

Roles and Work Process

Billing Specialist

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.

Medical Insurance Specialists (MIS)

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.

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Senior Insurance Consultants (SIC)

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.

The DocSystems Case in Four Scenes

Central Characters

• Jim: Senior Director, Customer Service, DocSystems
• Dave: Organization Development Consultant, DocSystems
• Rosie Jones: Medical Insurance Specialist, DocSystems
• Carlos Chavez: Senior Insurance Consultant, DocSystems
• Michelle: Senior Insurance Consultant and Carlos’s colleague, DocSystems

Scene 1: The First Client Meeting

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?