For claims and pricing teams, managing fee schedules can be a massive headache.
With Medicare undergoing major quarterly updates as well as policy adjustments and retroactive changes coming in regularly, fee schedules require constant maintenance. Add in Medicaid policies and rates, perhaps across different states, and the lift begins to grow exponentially. And when there are new codes and policies coming about rapidly, such as we saw this spring with changes around the handling of COVID-19 testing and treatment, it can be nearly impossible to keep the information up to date.
Researching these updates and then manually loading fee schedules into a system requires time that many payers could devote elsewhere. Furthermore, ensuring that all information is accurate, and current, is a time-consuming process that is vulnerable to human error and leaves plans at risk of non-compliance or delivering over- and underpayments to providers.
In the ever-evolving health care landscape, health plans need a way to automate these processes. They need technology solutions backed by a policy team that handles the heavy lifting, takes care of the research, and manages and loads in fee schedules automatically, with rates and policies modified, tested, and operational on or before the effective dates. With cloud-based delivery, health plans do not need to lift a finger. This lowers costs, increases operational efficiency, and mitigates risk from a compliance standpoint.
This is an important issue not just for claims pricing teams, but for multiple areas of health plans. In HealthEdge’s recent independent Voice of The Market Survey, a study of 245 IT executives at leading health plans, the top challenge these individuals cited with their organization’s core administrative processing system, was low claims accuracy and auto-adjudication rates.
But not all health plans are the same, and every insurer has different contracts and unique billing requirements. Payers need the flexibility to configure their system to meet their specific business needs. They need a technology that can easily apply certain policies updates that match their business structure. With fee schedules loaded in and configured in a way that matches their business, health plans no longer need to worry about policy changes impacting their day-to-day business operations.
With less maintenance on the system and additional flexibility to make real-time updates, resources can be re-directed to more productive and innovative tasks. Empowered by the right technology, health plans will have improved accuracy, reduced waste, and adaptability in a changing marketplace.