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Why Automation Technology Will Disrupt Claims Processing


Automated claims technologies are uniquely positioned to increase accuracy of claims because:

  • Most claims paid by health insurers are based on predetermined rates
  • Medicare and Medicaid policies change frequently

Pricing Accuracy is a Blue-Chip Item

Pricing accuracy is a continual concern due to:

  • Today’s fee-for-service (FFS) claims processing landscape
  • Frequent disputes and time-based fees or penalties from inaccurate claims
  • Continued expansion of data sources such as:
  • Claims
  • Encounters
  • Enrollment forms

Claims, encounters, and enrollment forms all need to be reconciled to accurately pay fee-for-value (FFV) methodologies like the payment bundles and shared savings programs being implemented nationwide.

Inaccurate Claims Lead to Disputes and Time-Based Fees or Penalties

Millions of identified underpaid or overpaid dollars are waiting to be reclaimed by the overpaying payer or the underpaid provider, creating disputes and time-based fees and penalties.

What makes these inaccurate claims (that increases claims management risks) so prevalent?

Updates are impossible to keep up with using standard practices.

These standard practices include relying on disjoined technologies or SMEs to manually establish library changes. Disjointed technologies update content libraries sparsely and fail to do so as a single system. Manual changes by SMEs are time-consuming and impossible to do profitably while staying in compliance.

Both lead to claim errors and rework.

Effectively and profitably accommodating daily updates to policies, methodologies, and rates will instead require investment in single interoperable automation technologies.

Medicare and Medicaid Experience Policy Changes Almost Daily

Centers for Medicaid and Medicare Services (CMS) publishes daily transmittals to communicate new or altered policies, rates, and other specific modifications. These can include retroactive changes to claims payment rules dating back months or even years. On average, using standard methods, libraries are updated every quarter, a far cry from the daily needed updates to stay compliant and avoid rework.

With a comprehensive and interoperable automatic claims technology, policy changes are updated at least every two weeks – saving health plans costly and complex rework on millions of claims.

Most Claims Are Based on Predetermined Rates

Commercial in- and out-of-network payment arrangements are often based on predetermined Medicare payment methodologies like:

  • MS-DRGs
  • APCs
  • Other prospective payment baselines like third-party case-mix groupers

The complexity of these payments partnered with standard practices like manual entry and disjointed technologies, lead to millions of errors in pricing.

Automating these complex claims with a single interoperable technology solution is the only proven effective method for eliminating these errors.

How Address Claims Payment Accuracy

To optimize payment accuracy, health plans are slated to invest in interoperable, customizable claims automation technology.

Vendors should be screened for ability to integrate into current workflows, comprehensiveness of training and strategic business alignment.

Learn more about claims payment accuracy or how to find the right technology vendor here.