posted by Burgess
on January 28, 2020
Imagine an expectant mother has high blood pressure and sees a specialist. After the visit, the provider submits the claim to her insurance plan, and from there it goes through a lengthy administration process. The insurance plan performs complex eligibility and benefits checks, provider contract checks, claims editing and pricing checks, and pushes the claim through several internal and external third-party solutions. Eventually, a reimbursement amount returns, but it moves to a medical records review, and is sent back for another trip through the process.
This case illustrates the complexities that often occur in the claims workflow. There are many time-consuming and redundant steps — sometimes more than 100 — to proper reimbursement. With this system, it’s evident why there is so much uncertainty about how much the expectant mother will have to pay.
But what if patients could pay the correct amount for the care they receive with full transparency of fees the moment a healthcare professional renders service? We can move closer to accurate point-of-service payments in healthcare, but we need advancements in technology to get there that include:
Technology is rapidly advancing what is possible, but big problems remain with how our industry manages data. Currently, health plans often rely on outdated systems, manual administrative tasks, and disjointed data, making payments inefficient and inaccurate. To accommodate this process, your organization likely has several disconnected systems that don’t work easily together. This fragmented method leads to issues of wasted time and resources that should — and can — be remedied.
Data is complex in all industries, but this is especially true in healthcare. From differences in medical formats and standards, to a multitude of code sets, to unreliable patient and claims history, data management is a huge challenge. Add the frequency of updates to healthcare policies and regulations, and the issue of keeping data accurate in payment management is magnified.
Traditional on-premise solutions rely on misaligned, manual, and infrequent data and policy updates. With this method, it can take months to implement an update, and these updates often occur several times each year and rely heavily on internal IT support.
In contrast, cloud-based payment delivery systems place your entire payment ecosystem on the Internet, allowing software and services to be updated in real time. Systems housed in the cloud offer frequent data updates delivered remotely, enabling you to always work with current information. The cloud system reduces IT maintenance delays, allowing rapid updates without using internal resources, and — crucial to point-of-service payments — delivering centralized and accurate data.
Traditional claims payment systems require substantial workflow management and manual effort which increases operational overhead costs and creates uncertain results. But what if we thought of the claims payment system as a whole, where software, data, and service platforms were brought together in an integrated ecosystem? An integrated ecosystem eliminates communication errors, delivers prepayment accuracy, and decreases the odds of human error. Ecosystems provide streamlined, actionable results to your health plan, and open doors to refocus the time and effort of your staff.
Tools like single-instance solutions are designed to natively incorporate several functions that work together, connecting to multiple claims systems while delivering streamlined and consistent results. When disparate functionalities like editing, pricing, and business intelligence are brought together in a single solution, it eliminates communication errors that often occur between systems not natively built to work together.
Single-instance solutions should be extensible to ensure access to best-of-breed data and functionality. Incorporating other leading solutions into a larger and more consistent workflow creates an integrated ecosystem for applying your policies and business rules to your claims.
When claims payment processes utilize integrated ecosystems, claims data is readily accessible to enable actionable, predictive analytics. This real-time information delivers enterprise-quality results that impact future decisions like new product launches, acquisitions, and commercializing services in the marketplace, giving you the unique ability to plan based on proven what-if scenarios.
Ultimately, an integrated ecosystem delivers a single, accurate outcome — an essential component of enabling point-of-service payment success. Integrated ecosystems relieve health plans and payers of a myriad of burdens, including administrative overhead, inaccuracy, and the need to recover costs, while empowering powerful business intelligence.
Emerging healthcare technology solutions enable automation in the claims process, taking all the human elements (e.g., policies, edits, pricing, adjudication) and creating an ecosystem so well-designed that manual efforts are nominal if not eliminated entirely.
To enable automation, health plans must employ technologies that consider:
Interoperable solutions seamlessly tie together disjointed components of the payment process so that complex communications can be translated into a common language. This ensures that results are streamlined, and true accuracy is achieved.
With automation and smart workflow, disparate solutions can be modified to have synchronized update cycles. Solutions that are passing information back and forth can share up-to-date data, and health plans can make intelligent decisions based on this information.
With an interoperable, accurate solution in place, a cloud-based environment makes it easy for health plans to scale for their evolving needs. Automation costs significantly less than manual work, operates around the clock, and is less vulnerable to human error, which is why it is pivotal to point-of-service payments. It also has a substantial impact on a patient’s experience, where they can trust their health plan and provider to deliver upfront and accurate billing.
Despite best efforts to modernize their payment integrity processes, many health plans still do not seamlessly automate and connect their disparate systems or integrate solutions that allow them to scale for evolving needs. We need to stop applying quick fixes to a broken system, and instead look at tools that enable an ecosystem to support lasting change.
Moving our industry toward accurate point-of-service payments cannot happen overnight. The task may be daunting, but we must understand how to set up the industry for success by addressing the following steps:
For health plans currently using a traditional approach to claims payment operations, developing an integrated ecosystem requires significant transformation of your entire organization and how you approach payment integrity. Payers can initiate this approach by creating payment integrity and transformation teams, staffed with representatives from IT, claims processing, and other stakeholders, then choosing a technology provider to help support this transition. Payers can also make payment integrity and point-of-service pricing part of their key performance indicators and long-term goals.
When we consider the time and money spent working to pay a claim correctly — such as a claim for a specialist visit for an expectant mother — there’s no question that change needs to occur. But who is responsible for fixing this system and creating the ideal solution? Simply put, the payers and technology providers in the healthcare industry have the unique power to push the industry forward. With an automated cloud-based ecosystem, we are laying the groundwork for many advances that can save time and money for payers while moving us closer to point-of-service payment accuracy.