Season 1, Episode 7

Innovations In Claims & Payment Models


Show Notes

It’s hard to imagine a time when claims were submitted on paper. In 2003, Medicare required electronic submission of all claims via an electronic data interchange (EDI) for auto-adjudication. This means claims are processed, paid, and have a status update without human contact. Plans should aim for an auto-adjudication rate in the high 90’s, but some systems still struggle with this benchmark.

There are a number of system errors that can impact auto-adjudication rates including faulty matching logic, incorrect claims information, and missing provider contracts to name a few. Information maintenance is critical to a successful auto-adjudication process, otherwise it front-end rejects or receives a pending status. In these cases, a manual correction is required and not preferable, as human resources are costly. In order to stay competitive, plans have to invest in a strong adjudication engine that can handle high volume.

Another area of investment that behooves plans to prioritize is the configurability of their claims processing technology. A high level of configurability allows for faster response to change such as: CMS regulatory updates, changes to the health plan’s plan types, benefit plans, contracts, provider contracts, capitation-related contracts, payor information, bank information, group information, member configuration, authorizations. There are a number of variables that must be accounted for and having a system that is highly configurable takes the edge off of changing with the times.

About Our Guest

Kirsten Lynch is a product manager and claims technology expert who has been in the healthcare industry for over 20 years. 

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