Many factors can impact the claims payment process. With so many legacy solutions still present in the market, there is significant opportunity for inefficient processes to slow down work or create inaccuracy. Without the right tools, even the processing of a single claim can drain a payer’s time and resources and strain provider relations.
Consider this. When a claim is submitted on some older systems, edits and errors come back one-by-one – only returning the most egregious error. The claim could be missing date of birth; the claim processor fixes that. Then they send in the claim again and find out the address is wrong and need to fix that. Sometimes these edits require contacting the provider and either resubmitting the claim or gathering the correct information. There could be dozens of bounce backs with a single claim and multiple changes and phone calls that need to be made separately. Health plans need a system that automates this process in real-time. They need a technology solution with advanced logic that can match a claim to the correct provider contract, know when and if a claim needs to run through a third-party solution, and allow the claims processors to resolve all errors at once. Streamlining the parallel process of edits means less back-and-forth and a faster resolution.
Another major factor in improving provider relations is the ability to quickly answer questions and give providers the confidence that payments are handled appropriately. In HealthEdge’s recent independent Voice of The Market Survey, tapping the insights of 245 IT executives at leading health plans, 28 percent of respondents cited lack of transparency for internal/external stakeholders as a top challenge with their core administrative processing system.
A payer does not want to take time and effort to chase down information from a variety of sources. Whether for internal or CMS audits or provider inquiries, health plans with access to a complete audit trail of how a claim was processed can readily defend payments, and providers can clearly understand the reasoning.
By employing new technologies that enable parallel processing and complete transparency of claims adjudication through audit trails, health plans can enhance operational efficiency, improve communication, and ultimately strengthen provider relations and overall satisfaction.