While claims automation might not totally eliminate claims errors, it does reduce them and helps
insurers cut costs, experts say. And more health insurance firms are deploying technology to automate
processes.
“Based on conversations I’ve had with people,
whether it’s from the vendor or health plan communities, this is a growing concern in health insurance
and carriers are actively looking to change their legacy
platforms and implement these solutions for a better,
more streamline approach,” says Kunal Pandya, senior
analyst, Health Insurance and Payments, at research
and advisory firm Aite Group.
“The top players are already doing a great job;
they’ve been looking at claims automation to bring
costs down and to make the processing of claims more
effective,” Pandya says. “The tier-two and three players are still getting to know these systems better or are
in the process” of implementing them.
For many insurers, claims are still being processed
largely on a manual basis, Pandya says, and those
firms should be eager not only to reduce errors but
reduce the cost of processing.
“Claims transactions are very complex from origi-
nation to payment,” Pandya says. “The processing
involves multiple financial and non-financial transac-
tions that go into processing one claim.”
Manual processes might cost about $9 per claim;
whereas it’s less than $1 for electronic processing, Pan-
dya says. Those costs include staff resources, postage
and other factors, he says.
“Claims transactions are very complex
from origination to payment,” Pandya
says. “The processing involves multiple
financial and non-financial transactions
that go into processing one claim.”
—Kunal Pandya, Aite Group
Claims ExCEllEnCE
Blue Shield of California in San Francisco has developed a program called the Partnership in Operational Excellence and Transparency (POET) to help
more than 180 hospitals in its network enhance the
claims process.
At the heart of POET is a Web-based dashboard
provided by MedeAnalytics Inc. that displays a rolling 36 months of finalized claims data, including details on cycle time, submission types, denial reasons
and appeals.
The dashboard, which is designed to report key
performance indicators customized for each provider,
provides the transparency necessary for Blue Shield
and its providers to have open dialogue, identify the
root cause of issues, and collaborate on workflow im-
provements, says Rob Geyer, SVP for customer opera-
tions at Blue Shield of California.
“With high-cost claims, providers who follow our clinical
guidelines and obtain prior authorizations on services
can submit most claims via EDi with no documentation,
which is the best way to ensure quick turnaround.”
—Rob Geyer, Blue Shield of California
ClEanEr Data
Arkansas Blue Cross Blue Shield and Pinnacle Business
Solutions Inc. also use various platforms to help with
claims automation.
The primary system is its provider Web portal,
known as Advanced Health Information Network
(AHIN). This is an in-house developed application built
on the AIX platform with a range of capabilities to give
health care providers information at the point of service, says David Bailey, EDI operations manager.
“Eligibility, claims corrections, claims status and fi-
nancial data are just some of the solutions within AHIN,”
Bailey says. “By providing physicians with better health in-
formation data, the claims they submit are cleaner claims,
thus improving the claims process tremendously.”
The Arkansas company began working with pro-
viders on the platform in 1995, Bailey says. “The rea-
sons for deploying this type of system were clear:
reduce operational cost and provide physicians the
means and solutions to better manage health infor-
mation within their organizations,” he says. “There
really wasn’t anything in place comparable to the
AHIN solution at that time.”
