The complexity of healthcare claims keeps rising as payers try to save costs, providers try to run their practises, and members try to find cheap and accessible care experiences.
Although the healthcare sector has made great improvements to the quality of care, the process for submitting and processing claims is still too complicated. Payers require a new platform to address the issue of misaligned incentives and reduce needless friction between stakeholders. However, it should be a platform that encourages integration over fragmentation.
Administrative expenses presently account for 30% of healthcare resources. (That amounts to 14% of all US spending annually.)
Billing expenses for medical practises are more than $30 billion annually.
Diverse systems are cited by 54% of health plan IT leaders as their biggest obstacle to digital transformation, according to a Deloitte poll.
Health plans are currently burdened with legacy systems as a result of decades of legislation and other market pressures that have produced an unmanageable collection of technology used to manage healthcare payments. Fragmentation, inefficiency, and complexity, however, are merely a result of how health payers got to where they are now.
Where did we come from?
The first thing a doctor needs when opening a practise is patients. The practise needs to enter into a deal with health plan directories to achieve that.
Once the practise has developed patients and joined networks, they are faced with the “rule” conundrum (e.g., eligibility verification, pre-authorizations, utilisation management review, claims submissions, denial management, etc.).
And as if those two steps weren’t challenging enough on their own, now consider all the other procedures associated with each payer network.
All of that must occur prior to submitting a claim.
The practise submits each claim to a clearinghouse, chargemaster, or revenue cycle management system in order to streamline the submission of such claims and guarantee payment.
After receiving a claim, the payer distributes it to third parties for editing, renegotiating the price, and out-of-network coverage. The claim may be fully, partially, bundled, or unbundledly denied. And the list goes on. Meaning: Paying a provider frequently takes months.
Add member responsibilities now.
The more time that elapses between providing a service and receiving payment, the harder it will be to collect the member’s obligation (which can only be billed after the payer determines how much they will pay). Speaking of stressful
The answer
Americans wanted options, but as the saying goes, “be careful what you ask for.”
In actuality, more options have simply made the healthcare system more convoluted. It is understandable that this system has produced the ideal environment for complexity with 400–500 payers, including TPAs and self-insured plans, and 800,000 doctors (all of whom perform different services).
Although technology can help bring about change, over many years, a lack of incentives led to the development of spot solutions, the majority of which are currently doing more harm than good.
Health plans must reduce claim and payment complexity while streamlining overall operations to enhance both the provider and member experience.
By lowering costs and complexity, an integrated payment and communication platform frees up resources to give members a cutting-edge shopping experience. However, payers must first objectively evaluate their current payment structures.
Organizations should consider a strategic technology partner that ensures access to advanced technology after evaluating their own dispersed systems and areas of concern.
What ought I to watch out for?
A network effect boosts the efficiency of the payment space (aka the concept that states the value of a solution increases when the number of people who use it increases).
As a result, it’s crucial to work with a specialised vendor that connects as many payers, providers, and members as feasible in a single system. Following that, plans might use and integrate technologies to speed effective, straightforward, and secure payments.
That’s not all, though.
To lessen the administrative complexity that is a part of healthcare administration, your vendor should provide an integrated payment and communication platform.
The Conclusion
Your business cannot evolve to meet changing demand if the underlying reasons of inefficiency in key administrative systems are not addressed, particularly as healthcare consumerism continues to have an impact on the patient experience.
The entire claims management process can be streamlined to save payers time and money and to enable meaningful interactions between providers and members that improve outcomes and save costs.
