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Top 5 Challenges of Payment Accuracy

Health plan payers receive hundreds of millions of claims each year. With such an inundation, it’s easy to understand how complicated and challenging payment processing can be. And when the slightest mistakes can cost you precious time and money, paying claims right the first time is imperative. Here are the top 5 biggest payment accuracy challenges and how to fix them.

  1. Inaccurate claims

Processing claims is an arduous and complicated task for any health plan. Pricing varies by region, specialty, and provider group. Other considerations like member seasonal geolocation add to claim payment complexity. With the high volume of claims and their associated complexities, inaccuracies happen – and they occur more frequently when being processed manually. The importance of automation for first pass accurate claims is extremely important.

  1. Inefficient processes

The payer world is constantly shifting, merging, and consolidating different organizations into one. When two organizations join, they often use different technology platforms that are not interoperable or don’t do the same task. In addition to the challenges of organization consolidation, many payer departments are definitively siloed, working in vacuums. Often, different technology vendors are leveraged across the organization for the same purpose – but serving different business lines. Implementing one technology platform for all lines of business supports a more efficient and streamlined organization.

  1. Changing fee schedules and regulations

Fee schedules are updated every year and adjusted by region; healthcare regulations are impacted by presidential administrations and external factors – like a global pandemic. Since 2019, over 3,000 pieces of healthcare legislation have been introduced to Congress as listed on Ultimately, 25 of those were passed into law which may not seem like an impactful number, but when measuring the many ways in which one law can affect healthcare billing, those changes can be overwhelming to keep up with and efficiently navigate. Penalties for non-compliance can be very costly, so adopting a platform that automates the implementation of new regulations is essential in today’s healthcare environment.

  1. Staying audit ready

The amount of tracking needed to perform and pass an audit at any time is daunting. Many payers know the pain felt when receiving an engagement letter from the Auditor-in-Charge at the Centers for Medicare and Medicaid (CMS). Beginning at that moment, the payer is responsible for filling out forms and providing appropriate documentation for CMS to conduct their audit. If anything is incomplete or amiss, the payer is at risk of failing the audit and incurring penalties. Technology that tracks all documentation needed for an audit and essentially creates an audit trail so that it’s ready whenever it’s needed, is an absolute game changer.

  1. Flexible technology

Lastly, for too long many healthcare organizations have been using legacy technology that isn’t particularly flexible, interoperable, or transparent. The pandemic made it abundantly clear that organizations able to come out ahead during this time of great healthcare transformation are those embracing and investing in technology that delivers all three. Automation for efficiency is certainly important, but it’s only one piece of a technology puzzle that can really propel a payer to achieving or even exceeding business goals.

HealthEdge’s payment integrity solution, Source, was built to specifically address the burden of each of these challenges. Listen in to the May AHIP webinar on May 5th where SummaCare details how adopting Source enabled them to tackle these top five claims processing issues. Register now.