“The Toothaches” QI team comprised the entire dental staff, from front desk clerk to dentist. The team decided use the DMAIC methodology and Six Sigma tools to address the issue.
After establishing a project charter, the team used four steps to define the problem. A stakeholder and needs chart was completed for clients, billers and employers, insurance providers, and the leadership team. Clearly, an enhanced billing process would benefit all stakeholders. Next, a cost of poor quality chart was completed, noting the dental program's pain points and annualized “cost.” In addition to resources, another cost of a poor dental billing process included low patient satisfaction. The team developed a line graph to display the lost revenue for each quarter of FY 2014–2015 and how it compared with the average and the target. Finally, a Gantt chart was used for the project’s timeline, which was completed over 7 months.
Six steps were then conducted to measure the problems with the billing process. First, a flowchart of the dental program billing process was completed, followed by applying the eight wastes. Identified wastes fell into the categories of defects and rework, overproduction, unused talent, and extra processing, and they provided insights for process improvements. Next, the team collected data on the reasons for denied claims, by quarter, for FY 2014–2015 and entered them into a spreadsheet. The data were entered into a Pareto chart, which identified “provider not credentialed” and “noncovered service or benefit” as the two problems that occurred most frequently (combined, they represented 88% of all problems). These same data were then used to show the denial amount (i.e., how much funding was denied for each reason for denials). Collectively, both problems represented 83% of the denied amount of funding and thus remained the primary areas for improvement. The team established two targets (a 70% reduction in claims denied as a result of noncredentialing and a 47% reduction in claims denied as a result of noncovered services). If achieved, these targets would reduce denials to $2,500 per quarter.
Next came a further analysis of the problem. A fishbone diagram was completed for both types of denied claims, followed by a root cause verification matrix. The matrices indicated that the credentialing problem was due to providers not being trained on the provider system, and the noncovered services were a problem because there was no written policy for noncovered charges. Equipped with this information, the team moved on to developing solutions.
For the improve phase, the team undertook three steps. First, the team developed a countermeasures matrix to address each root cause, resulting in seven practical methods. This step was followed by a barrier and aids analysis for the seven methods. The final step was to develop an action plan, using a Gantt chart, to implement the practical methods.
The final phase, control, is ongoing; staff developed a control chart to monitor the amount of lost revenue from denied dental claims on a quarterly basis.