It is estimated that 6-9% of healthcare claims contain errors. Every time a member of the claims team adjudicates a claim, there is a cost to the insurer. Automated adjudication of claims can radically reduce the cost of adjudication by as much as 10x. Still, to automate adjudication, insurers need to receive claims in the correct format, be sure that the data is accurate, and ideally only receive valid claims.
Receiving claims in the correct format
At the moment in Ireland, the majority of claims are received by insurers in paper format or as images of claim forms. Both formats still need to be entered into the Insurers’ claims management system and this involves scanning, OCR (optical character recognition) or manually inputting claims. This is time-consuming, and expensive and carries the risk of introducing errors into the process. Ideally, insurers would receive accurate claims data in the correct data format such as JSON or XML allowing insurers to automate adjudication.
Accurate claims data
It is estimated that OCR can be up to 10% inaccurate and even if the figure is a fraction of this, these errors mean that claims data cannot be fully trusted by health insurers. Leakages due to overpayment/underpayment of claims can only be identified if the underlying data is accurate. Moreover, the majority (approx. 70%) of a health insurer‘s costs are related to the cost of care. Therefore, in order to measure the outcomes of care the underlying data must be accurate and trustworthy. It is vital therefore that claims data is accurate if insurers are going to drive value for their members’ care.
Only receiving valid claims
Ideally, a health insurer would only receive claims that were accurate and valid. The claims would have been screened for errors and the errors would have been flagged to the hospital at the time of submission. This would mean that hospitals had the opportunity to correct the error and resubmit the claim without the insurer going to the expense of adjudicating the claim and then communicating this back to the hospital. The hospital would then correct the claim and resubmit it, cutting down on delays to payment for the hospital and the insurer would benefit by only adjudicating the claim on one occasion.
An ideal claims submission process would therefore be accurate, transmit claims in the correct data format, and screen out errors before they could be submitted. Insurers and providers stand to massively gain from the introduction of a system such as this and gains would be seen not only in the reduction of back-office costs but also in ensuring value for money in terms of improving patient outcomes.
MedoSync achieves all three of these outcomes by digitising claims, screening claims for errors before submission, and eliminating human error through automation and the use of a highly advanced and smart rules engine.
Healthcare is all about maximising our patient’s health and in order to do this we need accurate and reliable data to ensure that we allocate resources to areas with the best outcomes.
Hospitals are losing 6-9% of their revenue due to leakages in the billing process. MedoSync stops these leakages by creating the invoice in real-time and ensures hospitals get paid in full.
I am taking more time for reflection and writing up posts related to MedoSync’s areas of expertise: medical billing, healthcare, technology, and being a start-up in that ecosystem.