The claims operation is a core administrative function for both health plans and providers. As such, organizations rightly continue to focus on optimizing claims operations so that claims are processed more accurately, quickly and at lower cost. In addition to this important ongoing work, health plans and providers will need to prepare for innovations in healthcare which will significantly affect their claims operations.
Optimizing Claims Operations
We define this first category of focus as improving the performance of already existing claims operations. Ongoing investment in this area is important to ensure that organizations continue to maintain their financial health, serve their consumers and trading partners and maintain regulatory compliance. Organizational focus may include the following activities:
- Streamlining processes through business process reengineering/management
- Consolidating claims platforms
- Improving integration among disparate systems (e.g., membership, benefits, provider data and authorizations)
- Leveraging automation to improve auto-adjudication rates
- Investing in digital and mobile health
- Improving member and provider experience
- Investing in online portals to improve claims quality and reduce costs through member and provider self-service
- Improving operational and regulatory reporting
- Developing processes to support dual coverage plans
Optimizing claims operations requires more than a focus on technology. Organizations must make investments in people and process improvement, and data quality initiatives as well. Effective and efficient claims systems rely as much if not more on upstream processes and capabilities. If upstream systems produce poor quality or missing data, then auto-adjudication rates and claims automation will be low. Thus, a holistic and integrated approach that includes people, processes, technology and data is required when optimizing the claims system.
Preparing for the Future
The critical investments to achieve performance improvements today must be executed with line of sight to how the claims system should be strategically leveraged for the future. This is not happening today and is a critical disconnect. Executives generally have a vision of what capabilities their organizations will require in the future, but detailed requirements necessary to leverage their claims system as a strategic asset are often lacking. As a result, most optimization efforts fail to address future operating needs.
Existing claims systems and processes were designed for a world where health plans and providers worked in silos, and consumers and employers accepted restrictions in benefit choices, poor cost transparency and limited access to their health information. As providers and plans collaborate to solve challenges presented by new operating models such as coordinated care, this will profoundly impact their claims operations. Some providers will assume more risk and will need to develop administrative capabilities that have traditionally been managed by health plans. What will this mean for a health plans administrative systems? Will this lead to simplification or greater complexity?
Increasing consumerism in healthcare will also have profound implications for claims departments which are affected by a multitude of administrative systems and processes. In the future, consumers may want to create their own insurance product by designing their coverage, deductibles and premium. Additionally, consumers may have “continuous choice” in designating their benefit plans. For example, auto insurance consumers can currently log online at any time to change their coverage. Will consumers expect this from their health benefit plans in the future? How should plans and providers collaborate to share data, business processes, analytics and insights? What services should plans offer to providers? Will health plans and providers use claims and other clinical data to develop individualized care plans and reward individual consumers based on their health behavior? Is your current claims system agile and flexible enough to support this future state?
For most consumer products and services, consumers know the true and final cost at the point of sale. As consumers assume greater responsibility for out-of-pocket costs and premiums, they will demand to have cost transparency at the point of care. Delivering this will be an enormous challenge because it will require systems to adjudicate claims in real-time, and adjudicate claims accurately nearly 100% of the time. Enabling this capability will require better integration of the claims system with a host of other administrative systems that support eligibility, benefits, provider contracts, benefits accumulation, and member and provider portals.
To meet these future needs, organizations may need to pursue the activities including the following:
- Developing the ability to administrate new payment methods
- Improving the flexibility of administrative systems to support faster development of new products
- Developing a data and analytic strategy to fully leverage the claims data
- Creating the ability to share claims data, business processes and analytics between plans and providers through multiple channels including the cloud
- Disintermediating clearinghouses, allowing providers to directly submit claims to health plans
- Creating the ability to view and process claims through any device including mobile devices
- Reconfiguring existing claims systems and/or wrapping business process management capabilities around the core administrative system
T2C practitioners have deep experience helping clients implement claims systems, improve their operational performance and achieve compliance. We have helped our clients to optimize their performance by reducing their claims processing costs and turnaround time, achieving higher claims accuracy, and improving their customer service. Many consultancies can provide staff with technical experience configuring claims vendor products. T2C’s difference is that in addition to having experts with vendor product experience, T2C offers robust methodologies for determining our clients’ needs and creating end-to-end integrated solutions. We help our clients implement and optimize their claims systems to not only address today’s challenges, but to prepare them to meet the needs of a changing healthcare system.
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