Systems That Easily Integrate Necessary For Improving Claims Accuracy Rates

Once a health plan finalizes a claim, they do not want to go back and fix it retroactively. Claims accuracy rates improve productivity, reduce errors, and are critical to a health plan’s success.

In order to improve claims accuracy rates, health plans need a technology that integrates easily with all of the systems in your IT ecosystem and infrastructure and allows data exchange in real-time. Real-time data enables a payer to match the members to the right benefit plan and the providers to the right contract provisions to ensure the correct payment is applied to every claim. Without the proper tools, data matching can drain a payer’s time and resources and adversely impact the bottom line.

I worked with a Mid-West health plan that had clear key performance indicators they were looking to improve. They needed technology that integrated with their entire ecosystem and shared data to track their success metrics. They specifically needed a technology that could integrate with trading partners for eligibility, medical claims editing, grouping and reimbursement, repricing entities, provider credentialing, and more. They also needed a way to enhance member and provider matching, standardize USPS requirements and format, and provide latitude/longitude coordinates, among other things.

Their existing legacy technology could not configure or integrate their systems to track the necessary data. Their only options were a mixed-bag of technology to cover basic functionality and custom code to resolve integration gaps. Maintaining the integration was cumbersome, and upgrades required custom remediation. Furthermore, extending benefit information to external systems required interpretation of legacy table data, increasing the chance for error.

The health plan needed a next-generation system that worked in harmony with all other solutions in their IT ecosystem to achieve their business goals.

With next-generation technology, health plans can be self-sufficient. This enables implementations and ongoing maintenance of your IT infrastructure to be lower cost and lower risk than with a legacy solution.

Regulatory Compliance For A Competitive Advantage

advantages of regulatory compliance | healthedge

So many regulations are intertwined; health plans cannot ignore the ones that may seem insignificant. Every year these smaller regulation changes get bigger. However, there are also advantages of regulatory compliance that can benefit both the health plans and their members.

For example, the industry has been talking about provider directories since the mid-80s, but change was still very slow. The inhibitors to having up-to-date provider directories often moved initiatives for standardizing and updating the processes to the bottom of the priority list. CMS now has the ability to substantially penalize payers whose provider directories are out of date or otherwise inaccurate to the tune of $25,000 per member!

One of the key requirements in the Interoperability Final Rule is the Provider Directory API. This rule, enforceable in July 2021, highlights the importance of accurate and timely information about network providers for Medicare Advantage and Managed Medicaid. Health Plans operating in the CMS markets must take steps to ensure their data and processes to deliver the data are working properly, not just to be compliant but also to remain competitive.

Medicaid Managed Care, in particular, is evolving rapidly. A few years ago, most Medicaid recipients stayed with a fee-for-service Medicaid; they were not pushed toward managed care. Many states now prefer managed care over fee-for-service, as it is lower in cost and also preferred by an increasing number of members, as it provides more options and flexibility.

Medicaid is very fluid. A health plan with a Medicaid line of business must stay in-tune with what CMS is doing and how it interfaces with its state’s specific regulations. In particular, the business processes for Managed Medicaid enrollment can seem overwhelming. Daily full enrollment files are sent by the state, which must be translated into enrollment records that retain a historical view of all changes made throughout.

This deluge of information requires technology that can handle extensive slicing and dicing of the data. The enrollment record changes can impact everything from the available benefits for the member to their primary care provider assignment and even the amount payable for a specific service.

The enrollment data is required by core processing systems and must be viewable and usable by the health plans to properly address questions and other inquiries. Furthermore, these changes are typically time-sensitive, requiring that daily files are processed quickly and accurately and sequentially.

Many regulations are intertwined, some in conflict, some furthering a “cause” or process. The mission of all is to benefit the members, and in most cases, there are advantages of regulatory compliance to the health plans.

For example, health plans that focused on getting an updated provider directory in their claims system and also available to members create a win-win scenario! Members and potential members have the most up-to-date information, and health plans are processing claims without the worry of mass adjustments (or penalties!) down the road.

Everyone benefits!