This document proposes streamlining the medical billing appeals process using Lean Six Sigma. Currently, appeals are often sent without verifying coverage or eligibility, leading to unpaid claims. The project aims to reduce appeals processing time from 20 minutes to 5 minutes using automation. An analysis found the main causes of delays were improper verification and assigning appeals creation to billing staff instead of an dedicated team. The future state envisions an automated system allowing one person to process 96 appeals per day instead of 24. Progress will be monitored using a communication plan to refine the new process. An A3 problem-solving methodology will guide the project in developing a structured and strategic approach.

1. Streamlining Appeals Process in Medical
Billing using Lean Six Sigma
Prepared & Projected by
 Harry Smith(Hari Prasath)
 Rankin Raul(Ajith Babu)
 Richard Strange(Jinz Mohan)

2. DMAIC PROCESS
 AR & Denials are the major part in any RCM
process.
 Most of the denials can be self resolved rather
than sending the appeals with Medical records.
 Currently appeals are being sent to insurance
without even verifying if the codes are covered
or not and so on.
 Since appeals are sent for all the cases, the AR
may be piling up and if any incorrect appeal is
sent, we may end up in paying the insurance
through refund or recoupment and / or the
client may be unhappy after seeing the AR aging
bucket.

3. Define Phase (Project Charter)

4. Measure Phase(Paretto Chart)
 The Data was taken for the appeals which was sent
from January'19 through June'19 and the payments
from February'19 till July'19 after appealing on those
claims.
 Below is the time taken if one user is creating
appeals.
 480(8 hours on a day) / 20 (minutes for
preparing the appeal) = 24(Outcome of the
appeal)

5. Measure Phase(Current State)

6. Analyze Phase(Fishbone Analysis)
• Currently AR Team is analysing and working
on the claims. Whichever claims denied for
Medical records, claims are being
appealed. But there is a difference
between Medical records request and
sending the appeals. Appeals are being
created by the AR Team for few cases and
by the appeal team in few cases. For
creating an appeal it would take around 20
minutes and if the user is creating the
appeals, it would take much time and user
would not achieve the production target.
• Moreover in some cases appeals are being
sent to incorrect insurances where the user
missed to verify the fax number / address
which is a HIPPA voilation.

7. Improve Phase(Future State)
• If we are using the Automation team to
prepare an appeal based on different
software, an appeal would take around 5
minutes.
• 480(8 hours on a day) / 5 (minutes for
preparing the appeal) = 96(Outcome of the
appeal)
• A person can pe deployed for executing the
software and when the software is
executing, the same person can audit the
outcome of previously prepared appeals.

8. Control Phase(Communication Plan)
• After implementing this process, above is the communication plan to check if
the process is performing well.
• Based on the response the process will be streamlined.

9. A3 Tool
• A3 problem solving is a structured problem-solving and continuous-
improvement approach, first employed at Toyota and typically used by lean
manufacturing practitioners. It provides a simple and strict procedure that
guides problem solving by workers
• A3 thinking aims to develop. It can be summarized in 7 elements
– Logical Thinking – A3 represents a step-based thinking process.
– Presenting information in an objective way – there are no hidden agendas
here.
– Results and Processes – sharing what end results were achieved as well as
the means of achieving them.
– Sharing only essential information and putting it into a visual format
whenever possible.
– Whatever actions are taken, they must be aligned with the company’s
strategy and objectives.
– The focus is on developing a consistent perspective that can be adapted
across the entire organization.
– Developing a structured approach to problem-solving.