Health insurance claims management stands as a pivotal function within the industry, directly shaping customer satisfaction and operational performance. The process of claims management in insurance encompasses the end-to-end handling of a claim, from the initial submission of claims to the final settlement. This process not only tests the resilience and agility of insurance companies but also their commitment to serving their policyholders. However, this journey is fraught with challenges that can impede swift resolution. By understanding these obstacles and implementing strategic measures, businesses can enhance their insurance claims management processes, bringing faster resolution and improved client satisfaction.

Identifying the Challenges

The path to effective insurance claims management is often obstructed by several key challenges:

Complexity of Claims Processing: The intricate details involved in assessing claims, including the verification of coverage, validation of the claims, application of member plan coverage benefits, and determination of payout, can significantly delay the resolution process.

Data Management, Security, and Integration Issues: With vast amounts of data flowing from various sources, insurance companies often grapple with integrating this information efficiently, leading to bottlenecks in claims processing.

Regulatory Compliance and Fraud Prevention: Navigating the tightrope of regulatory compliance while also implementing measures to detect and prevent fraud adds another layer of complexity to claims management.

Customer Expectations: In today’s digital age, policyholders expect quick, transparent, and easy-to-navigate claims processes. Meeting these expectations requires insurers to leverage technology and streamline operations.

Excessive Administration Cost: The U.S. healthcare system racks up higher administrative costs than any other healthcare system in the world. Private health plans alone spend $158 billion on administrative costs each year, with average administrative costs per payer hovering around 17.8%. Factors include multiple touch points, failure to address paper-based processes, human intervention to adjudicate claims, cost of reprocessing, legacy systems, etc.

Overcoming the Challenges

To navigate these hurdles effectively, insurance companies can adopt several strategic measures:

Leverage Advanced Technologies

Implementing advanced technologies like AI and machine learning can automate routine tasks, enhance decision-making, and improve the accuracy of claims assessments. This not only speeds up the process but also reduces the potential for human error. We’ll dive further into this in the next section.

Enhance Data Management Capabilities

By adopting robust data management systems, insurers can integrate data seamlessly from various sources, providing a unified view that facilitates quicker and more informed decision-making.

Strengthen Fraud Detection Mechanisms

Utilizing predictive analytics and data mining techniques can help insurers identify potential fraud early in the process, thereby mitigating risks and ensuring faster claims resolution.

Focus on Customer Experience 

Streamlining the claims process through digital platforms, such as mobile apps and online portals, can significantly enhance the policyholder experience. Providing transparent, real-time updates on the status of claims can help meet and exceed customer expectations.

Continuous Training and Development 

Equipping claims management teams with ongoing training and development opportunities ensures they are current with the latest industry trends, regulatory changes, and technological advancements, further optimizing the claims process.

The Role of Technology in Streamlining Claims Processing

Technology revolutionizes insurance claims management by introducing efficiencies that transform how claims are processed. Robotic process automation (RPA) automates routine tasks, significantly accelerating the claims-handling process and allowing staff to concentrate on more complex issues. This shift not only speeds up operations but also enhances accuracy and reduces costs.

Advanced data analytics and predictive analytics are pivotal in processing vast amounts of data swiftly, improving risk assessment, fraud detection, and customer service. These technologies enable insurers to anticipate trends and potential problems, streamlining the decision-making process.

The adoption of digital platforms and mobile applications enhances the customer experience by providing transparency and convenience in submitting claims and receiving real-time updates. This digital approach meets the evolving expectations of policyholders and providers, fostering trust and satisfaction.

Artificial intelligence (AI) and machine learning improve the precision of claims assessments and aid in identifying fraudulent activities, ensuring fair resolutions and safeguarding against losses. The seamless integration of modern technology with existing systems enhances data sharing and collaboration, further speeding up the claims process.

In summary, leveraging technology in claims management not only expedites resolutions but also improves accuracy, customer satisfaction, and fraud prevention, marking a significant advancement in the insurance industry.

Streamlining Health Insurance Claims with Exela’s PCH Global

Take a step into using advanced technology with Exela’s Claims Processing solution starring our cutting-edge PCH Global platform. PCH Global revolutionizes health insurance claims processing by integrating data across all communication channels for smarter, more efficient processing. Our system performs crucial pre-submission checks to ensure cleaner claims and intelligently routes them for faster processing, leveraging advanced decision-making technology.

PCH Global significantly improves efficiency for payers and providers, cutting down pended claims by over 30%, reducing redetermination requests by 21%, and decreasing clinical edit exceptions by 24%. Our HiTrust-certified infrastructure supports digital submission of claims, records, payments, and correspondence, facilitating seamless communication between all parties involved and streamlining the entire claims lifecycle. The data is stored in the cloud and accessible through multifactor authentication.

Our platform empowers providers to pre-clean claims, reducing errors and speeding up exception handling through an intuitive online portal. With automated data capture and appeals routing, PCH Global enhances operational efficiency and keeps users informed on appeal statuses, improving turnaround times.

Leveraging iterative feedback and predictive analytics, the system continuously learns and adapts to changing payer rules, ensuring flexible and proactive claims management. It meticulously tracks transactions for clear audit trails and compliance, while securely managing digitized claims for optimized workflow communication.

Strategies for Success: Elevating Insurance Claims Management

Insurance claims management is a critical function that directly impacts a company's reputation and bottom line. By understanding and addressing the challenges inherent in claims processing, insurers can adopt strategies that promote efficiency, compliance, and customer satisfaction. Leveraging technology, enhancing data management, strengthening fraud detection, focusing on customer experience, and investing in employee development are key to overcoming these obstacles. 

As the insurance industry continues to evolve, embracing these strategies will be crucial for insurers looking to achieve faster claims resolution and secure a competitive edge in the market. Exela’s business process management (BPM) suite of solutions adds value to insurance company offerings and helps members receive the best possible value. With Exela’s Claims Processing solution, experience a future-focused approach to claims processing that provides accuracy, efficiency, and compliance in every step.

The relationship between providers and payers has often been seen as fraught with tension and mistrust built between the two parties. However, this is a common misconception. Providers and payers continually work toward a more collaborative relationship, using technology as a way to enhance their collaboration.

While there may be challenges between providers and payers, technology has smoothed the path, making it significantly easier for the parties to communicate and share data. Automated claims processing has proven to be an effective tool for both providers and payers to streamline processes, quicken outcomes, and enhance communication. Through this healthy collaboration, providers and payers can create a better experience for all stakeholders.

How Providers and Payers Interact

Providers work one-on-one with patients building strong relationships with their patients, providing care and treatment, and ultimately submitting claims to payers for reimbursement of services. Payers can provide a different viewpoint, while considering patient care, they focus on financial risk management. By combining these two experiences, providers and payers work toward a common goal of providing quality care, enhancing patient engagement, and achieving revenue goals and reduced costs.

The general interaction between provider and payer is a tale as old as time in modern America. When a patient wants to set up an appointment with a provider, the provider will confirm if they accept the patient's insurance along with confirming any pertinent benefits. Assuming the provider accepts the patient's insurance, the patient will then visit the provider, wherein the practitioner will detail notes regarding the patient's health and subsequent needs. This medical record is directed through coding, billing, and claim generation prior to sending to the payer. The payer receives the claim, reviews, accepts, suspends, or denies it. That’s the story in a nutshell.

The relationship between provider and payer is constant, both entities looking to save costs while providing the best customer experience they can.

The Challenges on the Road to Collaboration

Despite providers and payers having a collaborative relationship, there are still many challenges that they face including:

Difficulty sharing data and communicating - Payers and providers need to have the technology available to share data and communicate easily. Without this technology, the entire process could be quite lengthy. Exela’s automated claims processing solution provides a mechanism for digital exchange of documents and communication, and identification and correction of certain-to-be-denied claims, simplifying the process to be smooth and efficient.

Delays in communication - Traditional communication involves mail and telephone, both of which may cause delays in sharing information and can be difficult to track. On the other hand, a digital communication channel enables 24/7 contact and provides an auditable trail if either party needs to refer back to any previous communication.

Inefficient manual work - Paper documents are still common in the healthcare world creating manual work and delayed processing. Going digital enables efficient and accurate processing, while enhancing user experiences.

Automated Claims Processing Saves the Day

The answer to helping payers and providers create a more seamless collaboration is technology, specifically automated claims processing. Exela's PCH Global solution enables claims processing, optimizing the claims submission process driving successful reimbursement outcomes. PCH Global performs eligibility checks, clinical validation, and automates claims editing and submission. For payers, PCH Global offers automation of the full claim cycle including enrollment, claim submissions, processing adjudications, and processing payments.

PCH Global provides direct digital communication between all parties resulting in reduced friction and streamlined processing. Exela's automated claims processing platform can reduce pended claims by more than 30%, reduce claims redetermination requests by 21%, and reduce clinical edit exceptions by 24%.

By using PCH Global, providers and payers can easily communicate, manage claims, and collaborate to ensure that both parties are satisfied. It's time to create a beautiful alliance between payers and providers with automation leading the way.

Technology Paves the Way to Success

A successful collaboration can provide the best reimbursement outcomes for payers, providers, and patients. Communication is the first step to collaboration and automation can smooth out any bumps along the way. Automated claims processing such as Exela’s PCH Global can provide the leverage all parties need in order to overcome many of the challenges collaboration comes with. Make this collaboration a win-win with Exela’s PCH Global.

In the rapidly evolving healthcare landscape, "claims adjudication" is a term that carries significant weight. As a crucial link between healthcare providers, patients, and insurance companies, claims adjudication ensures that medical bills are accurate and that reimbursements are appropriately dispensed. With the confluence of modern technology and strategic approaches, the process of claims adjudication is undergoing a significant transformative phase.

The Necessity of Modernizing Claims Adjudication

Claims processing, in its traditional sense, has been fraught with challenges. One primary issue is the high volume of claims, which can be overwhelming and lead to errors and delays if not managed effectively. Coupled with this, manual claims processing methods can be time-consuming and susceptible to human error, resulting in incorrect payments or denied claims. Further, intricate healthcare regulations and continually changing coding standards compound the complexity, making it difficult to maintain accuracy and compliance.

By modernizing claims adjudication, payers can not only streamline their workflow but also significantly enhance accuracy, speed, and customer satisfaction. With the current workforce shortage and rising inflation costs, it’s becoming necessary to optimize workflows wherever possible.

Revamping Claim Adjustment with Technology and Outsourcing

Technology plays a pivotal role in transforming the claim adjustment process. Cutting-edge solutions like AI and machine learning can automate many routine tasks, significantly reducing human error. They can analyze vast amounts of data quickly and accurately, spotting anomalies that could indicate errors or potential fraud.

Moreover, digital platforms can integrate multiple data sources, providing a unified view of claim information. This integration enhances accuracy during the medical bill review process, resulting in more efficient claims adjudication.

In the midst of the ongoing workforce shortage, payers are finding it increasingly difficult to maintain an efficient and effective in-house team for claims adjudication. Staffing issues not only create bottlenecks in the claims processing pipeline but also stretch resources thin, leading to mistakes and inefficiencies. Outsourcing claims adjudication presents a viable solution to this challenge.

By partnering with specialized service providers, payers can leverage the expertise of trained professionals who can effectively manage the complexities of claims adjudication. This not only alleviates the burden on in-house teams but also allows for increased focus on core business functions.

Outsourcing also brings with it the benefits of advanced technology and automation capabilities that these specialized firms possess, enabling a faster, more accurate, and cost-effective adjudication process. As a result, outsourcing claims adjudication is increasingly emerging as the strategic choice for payers seeking efficiency, accuracy, and scalability.

Strategies to Implement

For an optimized claims adjudication process, payers can incorporate a variety of strategies. Firstly, leveraging technology such as AI and machine learning can automate routine tasks, reducing manual errors and speeding up the process. We’ve already mentioned this so let’s move onto the next strategy.

Secondly, regular audits can help ensure ongoing accuracy and compliance. These audits can identify systematic issues early, allowing for proactive resolution. Thirdly, investing in staff training is crucial. Well-trained staff can better navigate the complexities of healthcare regulations and coding changes, and apply appropriate processing rules by each line of business, resulting in more accurate claim processing. Alternatively, it may be worth looking into and prioritizing outsourcing.

Lastly, a clear communication strategy can enhance transparency in the process. By keeping all stakeholders informed throughout the claims process, payers can foster trust and build stronger relationships with both healthcare providers and patients. In summary, a combination of technology, regular auditing, staff training, and clear communication can significantly optimize the claims adjudication process.

Enhance Your Claims Adjudication Workflow with Exela

With over 20 years of experience and over 24 million claims edited and adjudicated annually, Exela understands and overcomes the challenges and obstacles of claims adjudication. We combine experts with technology to deliver a streamlined Claims Adjudication solution that scales to your needs, improves turnaround times, and provides a skilled team. Our workforce management team forecasts the volume and monitors the availability of the resources based on your requirements, providing continuous learning, cross-skilling and upskilling of the workforce while recruiting and training resources. Regardless of the change in claims volume, you have the resources ready at your disposal.

With extensive training, we ensure that our team has a wide variety of claim-type expertise giving them experience in end-to-end payer services. To make sure your company meets compliance standards, we provide a dedicated subject matter expert team that continually monitors changes in regulations that impact claims processing rules. Any change in regulation or payer policies is updated on our training and reference materials and delivered to our teams.

To help streamline the adjudication process, we supply a custom-built automation solution that simplifies workflows by taking over repetitive manual processes. The software tracks data from various systems making it easier to review the data and facilitate accurate and quick decisions. With the combination of our proprietary technology and our expert team, you experience lower costs, faster delivery, and improved reliability and productivity.

Take a Step into a More Modern Process

The road to modernizing claims adjudication is not without its challenges. However, with the right blend of technology and strategy, payers can streamline their claims processing and enhance their claims adjustment capabilities. With Exela’s long-standing relationships with large commercial payers and over 1,000 specialists, we have the expertise, consistency, and ability to unfailingly adapt to industry changes. Let us help you experience a modernized claims adjudication process that will provide enhanced efficiency, accuracy, and cost savings. Learn about our Claims Adjudication services today!

“It’s the prices, stupid.”

– a group of public health and policy experts in 2003, on

why U.S. healthcare spending is so high

The U.S. spends more per person on healthcare than any other developed nation, and it’s not because ours is higher quality or utilized more often by more people. Rather, it’s because the prices are higher.[1,2]” If only those higher prices correlated with higher life expectancy or lower rates of morbidity (i.e., illness and injury). Alas, they don’t, and the reason is widespread inefficiency in the U.S. healthcare system, and in particular healthcare administrative waste. For example:

- A staggering 60% of the U.S. healthcare industry is currently employed in administration, as opposed to providing patient care,[3]

- The average physician spends approximately half their day on administrative tasks.[4]

Such inefficiencies amount to approximately $935 billion in annual spending. It’s a terrifying figure, even before you consider it represents as much as one-quarter of all dollars spent on U.S. healthcare. With the U.S. still the world’s economic leader[5], the question is, what’s really going on here?

That, along with what can be done to turn things around before losing even more ground, is the focus of this quarter’s issue of Exela’s thought-leadership publication, PluggedIN: Tell Us Where It Hurts: How Tech Can Heal Healthcare. In it, we address the scope of the problem, its historical context, what’s been done thus far to address it, and why, as The Everest Group notes, “inefficiency remains pervasive in healthcare,” despite massive spending on both the part of the government and private interests.[6]Ultimately, we offer solutions—real world solutions ready to be implemented right now.

How do we know? Because we at Exela have the solutions and are ready to deploy them. As Everest notes in its 2019 Healthcare Business Process Automation Solutions PEAK Matrix Assessment,[7]Exela has been successfully prioritizing addressing healthcare’s inefficiencies—our innovative, AI-enhanced and well-priced solutions earning us a place at Everest’s “Major Contender” table in the healthcare space. Those solutions address the full gamut of challenges facing the healthcare industry, including:

• Medical coding
• Information release
• Claims processing
• Claims adjudication
• Provider data management
• Eligibility verification
• Revenue integrity

Our solutions also address challenges common throughout all industries, including:

• Billing and presentment
• Liquidity management
• Human capital management
• Lobby and reception management
• Mail services
• Print services
• Marketing Execution

Perhaps most importantly, however, they address the fundamental first “mile” along any organization’s journey into the process of business process automation/digital transformation: turning the vast and ever-increasing abundance of information in that organization’s possession, in whatever form it exists, into productive assets that can enter automated workflows for cost savings and be leveraged for the increased revenues. That requires both a macro-level of information governance and implementation of a process for enterprise information management. In the healthcare space, Exela offers comprehensive health information management solutions, tailored to healthcare’s specific challenges and goals.

PluggedIN is Exela's thought leadership publication, providing fresh insights from the cutting edge every quarter. Subscribe. Plug in. Upgrade your mind.

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[1] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.89

[2] https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05144

[3] https://www.americanprogress.org/issues/healthcare/reports/2019/04/08/468302/excess-administrative-costs-burden-u-s-health-care-system/

[4] https://www.focus-economics.com/blog/the-largest-economies-in-the-world

[5] https://www.exelatech.com/report/healthcare-business-process-automation-solutions-peak-matrixtm-assessment-2019

Nearly a decade ago, Harvard economist, David Cutler, famously called out Duke University Hospital for employing 1,300 persons to administer billing for only 900 beds. Apparently, that’s what it took in light of the many disparate requirements imposed by multiple payers (patients, insurance companies, the government) in every transaction. Nearly a decade later, healthcare automation offers efficient alternatives in billing as well as many other business processes.

Automated claims processing

As a threshold matter, automating healthcare solutions requires effective health information management. Health information management holds significant promise with regard to eliminating delays and denials in the claims process, which impact payers, providers, patients, and public health in general. Effective health information management not only directly addresses known issues in the claims workflow, but it is also a crucial first step in automating points along that workflow for optimal use of human capital, ROI optimization, and enhancing employee- and patient/consumer-experience.

To wit:

- For every process a payer or provider automates, there’s less need for manual intervention.

- Automated processing enables full visibility throughout the process.

- Intelligent data analytics tools help ensure efficient compliance efforts and enhance data privacy, routing related documents for the most efficient and appropriate reconciliation.

- Predictive analytics tools help providers and payers plan for uncertainties, including appeals and resubmissions.

By way of example, Exela’s deployment of our custom, self-service, rule-based healthcare solutions saved a top 10 payer an impressive 35% in the cost of processing claims and amounted to a 50% reduction in cycle time and a 20% reduction in resubmission rates. In addition, increased transparency for payers, providers, and members vastly improved employee- and patient/member-experience and reduced the demand for customer-service interactions. You can learn more in this case study.

Automating payments

Automating billing can be a game-changer by:

• Reducing the number of persons dedicated to the process, reducing time spent, and errors associated with, manual keying.
• Unifying payment data from multiple channels such as paper checks, debit transactions, collection procedures, etc.
• Enabling an improved patient communication strategy.
• Introducing other valuable efficiencies into the billing process such as HIPAA-compliant lockbox solutions.

In fact, we at Exela know how valuable such steps can be because we’ve seen it first-hand in solutions we’ve provided to our customers. For example, in the case of a major academic health system whose outdated payment operations had been mired in manual, error- and loss-prone processes, we deployed our Patient Financial Services suite to streamline information ingestion, facilitate communications, and optimize workflows, with the result being a 25% reduction in full-time employees needed for these operations and a 30% increase in collector efficiency. You can read more about it in this case study.

In addition to streamlining claims by avoiding denial of payment through improved coding, delivery of clean claims, and facilitating all related inter-stakeholder communications, automation can optimize revenue integrity through, among other things, data mining for the purpose of predictive analytics and revenue forecasting, all in the service of identifying and recovering all amounts in the most effective and efficient manner. For example, when a large healthcare system wanted a way to maximize reimbursement under their many payer contracts (all of which had different requirements, terms, and conditions), Exela deployment of its healthcare automation solutions resulted in 99.6% accurate reimbursement and identified 98.4% of underpayments and calculated predicted reimbursement under all payer contracts. “We look forward to continuing our relationship with Exela for years to come,” commented the customer in this case. “The contingency, success fee based engagement has provided an extremely positive, financial bottom line return, while requiring minimal staff time on our part...”

In addition, our medical lockbox solutions support providers in managing (and reducing the costs associated with managing) a high volume of receivables payments. And our newly-launched Real Time Payments solution can streamline the collection of remainders from patients using secure messaging and convenient payment options (via text message with payment options).

Automating accounts payable

It’s not just the core businesses of stakeholders that benefit from automation. For example, another of Exela’s customers, a national urgent care provider, had been processing more than 50,000 vendor invoices per month, resulting in lost documents and delayed payments to vendors, before turning to Exela to fully automate its burdensome paper-based workflow. In addition to streamlining payment to vendors and lowering the incidence of defaults and discrepancies, the user-friendly interface equipped the provider with the tools needed to readily address discrepancies if they arose and permitted the provider’s vendors to check invoice status online.

In the case of a major pharmaceutical company with a global footprint and driven by constant research and development, Exela was able to harmonize, digitize, and automate the more than 50,000 incoming invoices from 40 different business areas in 19 different countries through a custom-tailored combination of digitization services, data extraction, reporting, and remittance.

Automation Enrollment

Open enrollment is a payer-specific issue, and it’s always challenging. With ever increasing pressure to outperform the previous year’s results, there’s always a need for process innovation to meet increasing demands. Pressures are compounded by a short enrollment timeframe and employees who find the process confusing. The result is numerous queries and insufficient enrollment documentation. A large insurance company customer of Exela had been struggling with this scenario to the point that its satisfaction scores with providers and members were being severely impacted. Exela designed a universal intake and workflow solution to manage all the various modes of communication between the payer and the employees/potential members. In less than 90 days, Exela delivered 240,000 enrollment installations a month at a quality of 99.5% with significant cost savings in the form of reduced call volume and reduced pending items. Customer satisfaction soared.

Benefits to patients

The administrative complexity of the U.S. system also burdens patients, whether they are deciphering bewildering bills or shuttling records between providers. Three-quarters of consumers report being confused by medical bills and explanations of benefits. A Kaiser Family Foundation survey of people newly enrolled in the health insurance marketplace found that many were not confident in their understanding of the definitions of basic terms and concepts such as “premium,” “deductible,” or “provider network.” Insurers and employers spend an estimated $4.8 billion annually to assist consumers with low health insurance literacy, according to McKinsey.

For the full story on how technology can solve costly inefficiencies in the health industry, be sure to check out our Q4 Edition of PluggedIN: Tell Us Where It Hurts: How Tech Can Heal Healthcare.

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Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511963/

https://www.streamlinehealth.net/HIM-blog/revenue-integrity-can-organization-best-achieve/ https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/promoting-an-overdue-digital-transformation-in-healthcare