March 6, 2019
The health care industry is slow to advance technologically, and the limitations of many legacy systems lead payers to spend time and money fixing inaccurate payments. The claims payment process needs to be more efficient.
Take a look at the shortcomings of the claims process: Disconnected third-party solutions, complex policy updates, authorizations and regulations that affect claims, and the fact that the system works in a linear process that can’t handle today’s complexities.
Fortunately, there are health care IT solutions to address these issues. Advancements in interoperability, integrated ecosystems, and business intelligence allow efficient and accurate payments – the first time.
We’ve all experienced the pain of making updates throughout the claims process. With every change, whether small, like a fiscal year update to Medicare, or large, like the implementation of ICD-10 codes, we spend resources adjusting the claims payment system.
You interpret new regulations, develop requirements across your IT ecosystem, and finally, carry out the changes in the numerous vendor and home-grown solutions that utilize different data formats and update cycles.
When an editing solution is updated by a vendor on the 1st, a pricing solution on the 15th, and a prior authorization solution on the 20th, the process gets even more complicated. On top of that, government agencies, state programs, and Medicare update at different times, and can be late or retroactive. This complex environment leads to significant rework and manual review, and a higher probability of error.
Much of this chaos is because in the health care industry, we tend to search for solutions for current problems. We bolt on solutions to address specific issues, but this only adds disconnected pieces to a broken framework instead of fixing the problem at its core.
All these disparate solutions are also set up to work in a linear fashion. But if information is needed from a component further along in the process – for example, a medical records review performed after pricing – it’s nearly impossible to back up and fix anything quickly and accurately. This creates manual rework and a higher probability of error, causing conflict with payers and providers.
The technology to address these solutions continues to improve rapidly, but the health care industry is slow to adapt. Many organizations take on increasing operating expenses to support aging and ineffective technology rather than investing in upgrades to the system.
Why? Maybe they haven’t yet reached the tipping point.
For health plans, some of these tipping points could help push them toward new technology:
But perhaps the biggest tipping point is financial. Technological advances are inhibited by budgets and competing priorities, but neglecting to invest in the advances has led to billions of dollars wasted in administrative and manual claim rework. It’s estimated by the AMA that we would save 14 billion dollars annually by paying every claim correctly the first time. Every day we support outdated systems, we let profits slip away.
One major technological advance for our industry is interoperability—systems communicating seamlessly with each other.
Several research firms, including Gartner, have emphasized that without proper interoperability, payers receive unreliable information, resulting in poor service levels. When systems communicate effectively and exchange data accurately, it enables smarter integration and workflow, fewer translation errors, and complete information to the recipient.
But even when multiple solutions achieve some level of interoperability, there are other challenges. Each solution has separate licenses with contracts, fee schedules, IT updates, and client service teams to get support when there is an issue. Imagine how this challenge is magnified for payers dealing with 50 different point solutions.
These challenges can be solved with an integrated ecosystem, an enterprise platform with natively-built integration and workflow, so payment processes work together easily.
An integrated ecosystem:
In today’s landscape, with developments like value-based payments, accountable care organizations, and mergers and acquisitions creating new major players in the market, it’s truly a bigger risk to resist advances than it is to support them. But how do you approach selecting the best solution for your organization?
When choosing the ideal path:
For so long, our industry has put off technological advances because we think it’s too hard to change course. By embracing the evolution of healthcare technology, we can move toward optimizing care and the way we pay for it.