Capstone. class assignment

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Canada College *

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Industrial Engineering

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Feb 20, 2024

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3

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Delays in Healthcare Insurance Claims Processing: 5 Why’s model? Capstone Project Table of Content 0
Sno. Content Page no. 1 Introduction 2 2 5 Why’s Model and approach 2 Problem: Delays in Healthcare Insurance Claims Processing. 1
The "5 Whys" model is a problem-solving technique that aims to identify the root cause of a problem by asking "why" repeatedly, typically five times, until the underlying cause becomes apparent. Let's apply the 5 Whys model to above problem: 1. Why are there delays in processing healthcare insurance claims? Ans. Because the claim processing department has a backlog of claims to review. 2. Why is there a backlog of claims to review? Ans. Because the department is understaffed and unable to process claims as quickly as they are received. 3. Why is the claims processing department understaffed? Ans. Because the company has implemented cost-cutting measures and reduced staffing levels to save money. 4. Why did the company implement cost-cutting measures and reduce staffing levels? Ans. Because the company faced financial pressure due to rising healthcare costs and a decrease in revenue. 5. Why did the company face financial pressure due to rising healthcare costs and a decrease in revenue? Ans. Because the company's reimbursement rates from healthcare providers were not negotiated effectively, leading to higher costs, and there was a decline in the number of policyholders due to increased competition. Root Cause: The root cause of delays in healthcare insurance claims processing is a combination of ineffective negotiation of reimbursement rates with healthcare providers, cost-cutting measures, and reduced staffing levels due to financial pressure caused by rising healthcare costs and decreased revenue. To address this problem and improve claims processing efficiency, the insurance company should consider: Revising reimbursement agreements with healthcare providers to negotiate more favorable rates. Conducting a cost-benefit analysis to determine whether the cost-cutting measures are negatively impacting customer service and claims processing efficiency. Exploring strategies to increase revenue and attract more policyholders. Assessing staffing levels and reallocating resources to ensure the claims’ processing department has adequate staff to handle the workload. Implementing process improvements and technology enhancements to streamline claims processing and reduce delays. 2
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