Inefficiencies in healthcare payments, claims, and billing hinder provider cash flow and patient care as practices focus on administrative tasks. Strategic investments by health plans in technology and data can reduce administrative spending and streamline claims management and reimbursement, creating tangible benefits for payers, providers, and patients.
A single patient encounter comprises a litany of administrative activities:
- eligibility and benefit verification,
- provider referral
- claim submission, attachments, and coordination of benefits
- claims status inquiry
- claim payment and remittance advice
Recent findings by McKinsey & Company show that one-quarter of the $4 trillion spent annually on healthcare goes toward administrative processes (e.g., payment transactions, back-office functions, patient services). In 2019, private payers spent $180 billion, whereas hospitals and physician groups spent $250 billion and $205 billion, respectively.
The adoption of electronic transactions should help reduce this significantly large amount of spending on claims management and healthcare payments. Two standards are essential for submitting and paying claims. ASC X12N 837 is a HIPAA-compliant transaction set for claims submission. Its counterpart, ASC X12N 835, is the transaction standard for electronically transmitted payment and remittance. According to the 2021 CAQH Index, 97 percent of health plans have adopted electronic transactions for claims submission, and 76 percent and 64 percent have adopted digital transactions for claim payment and remittance advice, respectively.
Despite widespread adoption of the two standards, breakdowns are occurring on the provider end and creating back-office challenges and frustration. An 835 can fail to match with a specific 837, and commonly multiple 835 transactions are used for a single 835 or a single 835 corresponds to a multitude of 837 submissions. In such cases, providers struggle to connect payments with the appropriate claim and determine a remaining balance.
A solution to this breakdown must be able to synchronize these two transaction sets and streamline back-office activities for providers.
Essential role of data for healthcare payments
To maintain visibility across claims submission and payment workflows, data is needed. But data must also be organized to provide a comprehensive of each claim’s life cycle, especially information on claims and payments (and eventually patient financial responsibility).
“What is often missed is the fact that data moves between providers and payers multiple times, especially if some adjustments or corrections are made,” explains Landon Gordon, Chief Product Officer for the B2B Payments business unit at Optum Financial.
One area where data is lagging is the remittance process, in which a health plan sends an explanation of benefits and payments (i.e., an 835). Even with digital systems, a provider may struggle to connect the payment to the right claim and determine outstanding charges.
“Remittance data is likewise a crucial aspect of payments to help with reconciliation and resolving balances on claims. Having this data stream together allows for better innovation and decisioning to facilitate understanding of a claim or payment journey for providers.”
A failure to leverage comprehensive data can negatively impact provider practices, delaying payments (i.e., cash flow) and often leading to a blame game that fails to recognize that current systems and workflows are the true cause of breakdowns.
“Providers spend more time and energy on administrative work and less time caring for patients,” Gordon suggests. “Providers will use the health plan as the reason when their systems are difficult to manage remittance and payment adjudication. The solution is the use of digital systems that allow robust data to be shared and communication between payers and providers to eliminate the need for manual interaction.”
A single solution to simplify payments
While health plans have relied on a multitude of people, process, and technology to manage healthcare payments, their approach has led to silos that are the root cause of breakdowns in communication historically. By placing equal value on efficient healthcare payments as meeting policy and regulation requirements, plans can bring greater simplicity and transparency to their financial interactions with providers and patients.
“Payers industry needs to recognize the limitations on providers to reconcile breakdowns in reimbursement. A multi-modality payment delivery process is able to align the capabilities of the provider with the right payment method, driving both revenue and satisfaction with providers and consumers,” Gordon maintains.
Working with a strategic healthcare payments partner, health plans can address their present-day needs and better prepare for what lies ahead.
“How do technology companies help protect and secure health plan electronic transactions in a high-risk hacker environment? How can we help shape and adapt technological solutions that help health plans adapt to a consumer market payment environment with limited routine real-time payments? We can lead here in helping shape a direction,” says Gordon.
With new market entrants focused on consumer-oriented healthcare, providers expect greater competition for patients. Health plans must do their part to ensure that healthcare payments do not interfere with the provider-patient relationship. And that’s precisely where a strategic partner with a broad reach and deep technical skills can eliminate frustration around healthcare payments.
“By providing the payment decisioning and banking relationship, a skilled strategic partner provides direct connections between payers and providers rather than working through third parties, increasing the speed of payment delivery and payment certainty across all payment modalities,” Gordon emphasizes.
“Likewise, the right strategic partner builds new provider features that bring payment and data together in one place, traditionally where banks and others fail short. An additional benefit is the ability to bring new innovations to market quicker at a critical juncture for the healthcare industry, especially payers.”
Ultimately, simplicity comes down to visibility, made richer or more impactful when powered by timely data.
“When data can help create the views, it creates new levels of synergy across a claim’s entire journey,” Gordon concludes.
Source: HealthPayer Intelligence
