Performance

Constant, accurate monitoring of plan activity and market conditions is paramount to successful plan implementation. This issue is important for private and government sponsored health plans, given the need to remain compliant in a changing environment.

PGBA professionals are here with an arsenal of monthly and real-time reporting tools that keep payers and plan members informed of any and all details that can impact plan performance and customer satisfaction. From e-payment and contract management systems to paperless workflow systems and event tracking repositories, our tools give clients a proven advantage in managing plan data to ensure contract compliance and optimal plan efficiency.

Quality checks

PGBA uses a series of audits and auditing techniques to validate the quality of our service and products. With claims processing, we take a two-pronged approach to ensure our processes and systems generate quality results. First, we randomly select claims for pre-payment review as part of our quality assurance process. This method minimizes the impact to transaction timeliness while providing quality management checkpoints for accuracy. Second, we audit a sample of our own processed transactions weekly to determine procedural and payment accuracy. We then analyze error trends from both audits and develop corrective action plans to immediately resolve quality issues. Excellent audit results are met with praise and reward with best practices shared with everyone. These methods have proven effective over time, helping us achieve and maintain performance excellence. To date, our claims processing accuracy rates consistently exceed 99%.

Contract standards reporting

PGBA centralizes all reporting functions under a performance and reporting area. This area assimilates and reports monthly performance data to the management team for review. A Corrective Action Request (CAR) plan is prepared to address any performance weaknesses and prevent recurrence.  When circumstances threaten our ability to achieve stated objectives, we take immediate action launching preventive action plans to eliminate barriers to stellar performance.

Contact management system

PGBA offers inventory management through our contact management tracking system. This single, central repository for customer contacts can be integrated with PGBA telephony systems and our image-based paperless workflow system, or can serve as a stand-alone, manually populated option. Data collection and storage use customer-defined values for the source, reason and type of inquiry, recording all service activity from receipt to resolution. Value-added options include systematic population of pertinent data at various points within the system integration process.

In addition to housing all customer contact information, this system provides information such as first attempt resolution and aging of records. The data is stored in informational database tables that can be used for ad hoc reporting. Data analytics are available to support extraction of data for trend analysis, training, marketing and education or to support justification of system enhancements.

Event tracking repository

Event tracking is a value-added option that collects and stores all activity from an episode of service. Data is collected from all sources, including web, telephone, desktops and the PGBA contact management system. This system allows us to:

  • Trigger actions to resolve inquiries
  • Identify best practices
  • Monitor associate service patterns
  • Monitor caller service patterns
  • Analyze caller problems or complaints
  • Measure average service time per inquiry reason.

Image-based paperless workflow system

This workflow system streamlines business processes without sacrificing rapid access to information. It eliminates the need to manually handle paper documents by converting them into an electronic format for easier management and storage. Once documents are digitally captured and organized, workflow components move the electronic document quickly and automatically along defined routing paths for additional processing, approval or archiving. This function allows PGBA customer service professionals to respond more quickly to customers while keeping administrative costs down.

E-payment systems

Realizing the cash flow concerns of many healthcare providers today, PGBA engages in a fluid electronic funds transfer (EFT) program to help doctors, hospitals and other providers receive payments faster. This system is fast, easy, convenient and free.