Automated Processing Pays Off

Insurance Networking News, May 1, 2012

Bob Violino

"One of the major growth opportunities is educating providers on Blue Shield policy and business rules, including EDI billing requirements," Geyer says. "With high-cost claims, providers who follow our clinical guidelines and obtain prior authorizations on services can submit most claims via EDI with no documentation, which is the best way to ensure quick turnaround."

Before NetworX Pricer, Blue Shield used an internally created tool for pricing outpatient hospital claims. "While the tool serviced its original purpose of improving quality by auto pricing some of the less complex hospital contracts and services, it did not fully automate pricing, and claims still required manual intervention to be processed," Geyer says.

Since implementing NetworX Pricer, Blue Shield has seen a 30 percent increase in its automated claims processing, "which means hospitals' claims are getting processed faster," Geyer says.

Cleaner Data

Arkansas Blue Cross Blue Shield and Pinnacle Business Solutions Inc. also use various platforms to help with claims automation.

The primary system is its provider Web portal, known as Advanced Health Information Network (AHIN). This is an in-house developed application built on the AIX platform with a range of capabilities to give health care providers information at the point of service, says David Bailey, EDI operations manager.

"Eligibility, claims corrections, claims status and financial data are just some of the solutions within AHIN," Bailey says. "By providing physicians with better health information data, the claims they submit are cleaner claims, thus improving the claims process tremendously."

The Arkansas company began working with providers on the platform in 1995, Bailey says. "The reasons for deploying this type of system were clear: reduce operational cost and provide physicians the means and solutions to better manage health information within their organizations," he says. "There really wasn't anything in place comparable to the AHIN solution at that time."

Physicians had to contact customer service to discuss rejected claims, eligibility inquiries, or claims statuses, Bailey says. "Some of the shortcomings we learned about through the implementation of AHIN dealt with data loads, eligibility files, and member records," he says.

The AHIN platform has allowed Arkansas Blue Cross and Blue Shield to make significant improvements with data loads, eligibility lookups and member records, Bailey adds. "Over the years we've been able to clean up this data, which has resulted in a better process for all parties involved."

The company has seen significant cost reductions in various departments because of the portal, as well as an increase in accurate claims that allow for faster payments to providers. About 97 percent of the company's providers throughout Arkansas are using AHIN, Bailey says.

Another insurer that's benefiting from claims automation, Harvard Pilgrim Health Care, implemented the Oracle Health Insurance (OHI) claims application in 2011. By implementing the technology, the firm automates claims processes that had required manual intervention.

"We expect that by implementing OHI claims we will realize improvements in claims processing automation, accuracy and reporting," says Natalie Cunningham, director of technology operations and programs at Harvard Pilgrim Health Care.

The application is expected to process about one million claims transactions each month and increase auto-adjudication rates for Harvard Pilgrim members throughout New England. This will lead to faster, more automated claims processing and reduced operating expenses.

Examples of enhanced functionality the firm has already seen with OHI include automated late charge detection, automated COB calculation, automated interim billing detection, ability to define case/condition relationships across claims, and flexibility to determine order of calculation for member liabilities.

"It is still a bit early to quantify the operational impacts of implementing OHI claims; only a small percentage of our membership has been migrated to the new system to date," Cunningham says. "But as membership continues to be migrated over the next 12 months, we anticipate favorable results in auto adjudication rates and reporting capabilities."

Some insurers, such as BlueCross BlueShield of South Carolina, have developed their own claims automation platform.

"Over the past five years we have seen the first significant shifts toward real-time processing in the health care business, and this trend will only accelerate as retail purchasing models become more prevalent with implementation of health care reform," says Steele Pendleton, SVP of systems sourcing at the company.

"Consumers will expect to be able to enroll with a health plan, pay their bills and have their claims processed, all in real time," Pendleton says. "They will expect their deductibles to reflect activity in real time, so if they see a doctor and then head to the pharmacy, the pharmacy would know if they had met their deductible during the doctor's office visit. Our technology stack supports all of these functions in real time today."

For more information on related topics, visit the following channels:

• Claims
• Customer Service