Imagine an expectant mother has high blood pressure and sees a specialist. After the visit, the provider submits the claim to her insurance plan, and from there it goes through a lengthy administration process. The insurance plan performs complex eligibility and benefits checks, provider contract checks, claims editing and pricing checks, and pushes the claim through several internal and external third-party solutions. Eventually, a reimbursement amount returns, but it moves to a medical records review, and is sent back for another trip through the process.
This case illustrates the complexities that often occur in the claims workflow. There are many time-consuming and redundant steps — sometimes more than 100 — to proper reimbursement. With this system, it’s evident why there is so much uncertainty about how much the expectant mother will have to pay.
But what if patients could pay the correct amount for the care they receive with full transparency of fees the moment a healthcare professional renders service? We can move closer to accurate point-of-service payments in healthcare, but we need advancements in technology to get there that include: