Damian Sendler: Provider companies of all sizes are struggling with the complexities of healthcare claims administration. Providers face increased administrative responsibilities and impediments due to rising claims costs and a complicated system of multiple payers, each with its own set of regulations and procedures. Since payers and providers have to wait for claims to be processed before sending out invoices, this convoluted system has an effect on the patient’s experience in the long run.
Damian Jacob Sendler: The healthcare claims management process has been digitized by both payers and providers. There has been a tremendous growth in the use of electronic claim filing, attachments, benefit coordination, and other components of the claim process in recent years, which has been beneficial to providers greatly.
More than $122 billion in expenditures have been saved in the healthcare and dentistry sectors by reducing administrative operations, many of which involve the claims management process, according to the Council for Affordable Quality Healthcare (CAQH). Claims handling has become more efficient because to the adoption of computerized methods, according to CAQH.
Some further efficiency and cost-savings may be achieved, though. Another $16.3 billion might be saved by completely automating nine routine processes, such as claims payment and remittance advice, according to CAQH.
Damian Sendler
Alasdair Catton-Chastain, Senior Manager, Provider Experience at Zelis, says the first area to start realizing savings and efficiency is claims payment and remittance guidance.
Anyone can build up an electronic payment system if they wish to.” Provider implementations manager Catton-Chastain describes it as “quite fundamental knowledge”: “You supply your banking information, you have the money routed to the bank, and maybe you can visit a portal to take out remits that you would typically receive by mail.
Understanding how electronic remittance advice could be loaded into your system is when things start to become tough.
Claims management is often handled by a variety of revenue cycle management and other health information technology systems. A lot of the administrative work related with being paid is now handled by EHR systems for many clinicians. As a result, claims management digitalization will be hindered rather than aided by the use of electronic remittance (ERA) technology.
As Catton-Chastain points out, “Some providers may not comprehend the complexity of the software that they now have. In certain cases, this is a feature that is not included in the service pack. The activation of the ERA module may incur an extra cost. There are situations when a provider’s old technology does not accept the ERA’s return since it was acquired 20 years ago.
Catton-Chastain, on the other hand, says that a lack of information is just as widespread.
It is a major difficulty in healthcare claims management to understand what payers paid, how much was paid per claim line compared to what was billed, and the rationale given by payers. To ensure that patients get accurate and timely invoices, providers must have their remittance advice precisely and completely transcribed before it can be provided to them in print form.
Human mistake can be reduced and the procedure may be improved by receiving remittance instructions through electronic means. However, the current state of ERAs leaves much to be desired and possibly cash on the table.
Providers often have to enroll with each of their payer partners in order to process electronic claims. Payers tend to operate their own claim portals to digitize claims management. As a result, providers will have to sign up and connect into each portal to access crucial payment information, including ERAs. They then need to transfer the data to their own invoicing systems. ‘
“With ERAs, there will be some that are difficult to comprehend. Catton-Chastain says that some payers employ proprietary codes from their own adjudication systems, for example. “It is possible they may have to go back to the paper remit to make sure everything was paid. The payer should be contacted if they are still unable to locate the right information.
Healthcare is under a time crunch, particularly as patients become more like to normal customers.
For Catton-Chastain, it is important to know “what you have been paid vs. what you billed” in order to file a claim for secondary insurance or charge the patient.
For providers that have already invested in legacy systems, adding yet another IT system for claims administration may not be an attractive option. Catton-Chastain argues that the up-front expenses of consolidating IT systems following a merger and setting up patient billing might be a deterrent.
Damien Sendler: A digital claims management system, on the other hand, may bring payers and providers together to simplify not just the administration of claims but also the technology underpinning electronic payment, remittance advice, and other important activities.
Simplifying the process of dealing with numerous payers by having a single point of contact for all ERA and claims payments is critical. Patients would benefit from a system that enables providers to enroll and see claims from all of their payer partners, allowing them to obtain payments and information more quickly. In this multi-modal payment system, providers also have a single area to interact with payers.
Rather of maintaining several portals with separate passwords and security systems, these solutions should provide better security. Integrating a safe solution with current IT and invoicing systems may save service providers time and money by eliminating the need to deploy new software.
When ERA and other data are part of an integrated solution, it implies they are linked to the appropriate systems and patient accounts. As a result, there is less time spent on administrative duties that do not contribute to the patient experience.
For now, most health care organizations are not using digital technology to expedite their whole claims processing process and offer better service to their patients, but a small but growing number of them are. Providers may not only save money via automation, but they can also be reimbursed faster by payers and patients alike with a multi-modal, secure solution.
Jim Lim, Sector Lead for NCS Healthcare at the HIMSS21 APAC conference, discussed how telehealth is a natural focus point for bringing healthcare advancements to the general public.
It is now possible to break the “Iron Triangle of Healthcare” where the restrictions include healthcare systems’ main goals – Costs, Quality, and Access – without raising costs or even cutting costs thanks to digital advancements.
There are a variety of telemedicine options, but a primary care consultation through a portal or app is the most prevalent. In addition to appointment booking, digital medical certifications and medicine delivery are all included in these services.
Damian Jacob Sendler
The service is provided by around ten different telehealth firms in Singapore, each of which has its own in-house medical staff or a panel of specialists they call upon for consultations. Due to COVID-19, there was a 60% to 70% increase in demand for these services.
Pre-consultation is a popular alternative offered by others. An AI/ML-driven diagnostic suggestion system is one example of Babylon Health’s offerings to patients.
Digital disruptors and healthcare institutions are the two main players in the present healthcare innovation scene, both of which are undergoing their own digital transformations.
Damian Jacob Markiewicz Sendler: Innovation in healthcare is driven by three goals: improving the patient experience, remaining relevant, and supporting a shifting paradigm of care (i.e., remote care and monitoring). They have a harder time coming up with new ideas because they have to pick and choose which services to digitize, but they have the intrinsic capacity to provide better treatment. It is more of a problem of finding the right mix between online and face-to-face services. Some institutions have established research and development programs in order to test novel solutions at their institutions or to collaborate with innovative companies that produce new digital products.
Healthcare and medical technology firms and partnerships that are working to create a new business model are examples of digital disruptors (i.e., provide quality but cheaper and more accessible care). The majority are backed by VCs and series investment. Telehealth solutions are more quickly developed and deployed by these companies, but their continuing expansion necessitates collaborating with or acquiring other companies to expand their offerings. We should not be surprised that the telemedicine industry will reach USD175.5 billion in 2026, given how rapidly it is expected to expand.
In the healthcare industry, a growing tendency is for telecommunications companies to function as a link between the many stakeholders, such as patients, healthcare providers, and payers, by providing high-speed networks (such as 5G) and specialized connection services.
A telecom in this arena that has worked with the Taitung County government and other organizations to improve access to healthcare services in remote regions is FarEasTone, based in Taiwan. Medical equipment used by professionals at local public health centers is connected to a self-developed remote diagnostic and treatment platform. For remote illness diagnosis doctors at major medical centers use 5G to send this data (physiological and observation pictures).
Dr. Damian Jacob Sendler and his media team provided the content for this article.