Payers want to see their exposure, Providers want faster payments...
tldr; Healthcare Consumerization (needs) Real-time claims (needs) Real-time Payments (needs) Real-time Adjudication (needs) Advanced Claims Editing
The industry has been talking about real-time claims for some time now, however inspite of obvious friction in the current revenue cycle solutions and oft-repeated benefits (reduced DSO, reduced costs), when it comes to providers, the adoption rate is low. This, at a time when a miniscule %age of claims is currently processed while the patient is still onsite.
One of the key reasons cited is the need for faster/real-time payments ("RTP") (claims disbursements) - the provider position is understandable.. why have realtime claims, and then wait for X weeks to get paid? What about complex in-patient claims? Let's park this issue and instead consider simple FFS claims instead as a point of discussion.
RTP in Healthcare, in turn, means we need real-time adjudication platforms that will churn out claims disbursements immediately.. this is a $400Bn+ problem in the healthcare ecosystem (cost of provider claims administration) which drives the overall cost of care; and needs clarity in terms of "sure to pay" or "sure to deny" claims. If we get this clarity, we can then take on the more complex claims adjudication subsequently.
For claims edit validation, Payers have wide adoption of platforms at this time, however these systems are not being used for front-end submission, but rather as pre-payment validation checks. The healthcare ecosystem is better served using these validation rules, both as general payer guidelines as well as proprietary claims edit validation systems, to guide providers both in clinical care settings
e.g. ICD codes a,b,c are usually accompanied by ICD code d; and required by patient's insurance carrier).
Performing this level of claims validation at the outset requires closer collaboration between providers and payers, and a data sharing /communications capability that simply does not exist currently. Whether via EDI pathways or as a provider portal submission process, interoperability of platforms will put us on the right path towards reducing the onerous claims administration costs we all bear today.