Clean claims slide easily through autoadjudication systems


To achieve a higher rate of clean claims, health plans have to be absolutely clear on what a "clean claim" means to all parties in the transaction.

Key Points

TO ACHIEVE a higher rate of clean claims, health plans have to be absolutely clear on what "a clean claim" means to all parties in the transaction.

"A clean claim is the one that gets processed the first time, and we are not going to come back to the provider and ask for more information that is going to delay their payment," says Jay Eisenstock, Aetna head of provider e.Solutions.

The goal is the same on all sides of the transaction-a claim that is processed quickly-but the stakeholders may approach clean claims with different primary objectives. The provider wants to submit a claim that will not be denied by the payer. The claims clearinghouse wants to process a claim that makes it into the payer's system the first time. And for the payer, the brass ring at the center of claims activity is the claim that auto-adjudicates, sailing through its systems without resource-consuming human intervention.

But Eisenstock notes that by design, some complicated hospital claims will be stopped for review.


When claims are held up for manual processing, it costs payers more money, says Janice Jacobs, IMA consulting, but this fact often goes unrecognized by providers.

"There's an inaccurate notion that payers will hold back payment as long as possible. It is not in the payers' best interests to hold claims for manual review and follow-up phone calls by payer staff. The goal is the same: to adjudicate the claim quickly and efficiently," says Jacobs.

But providers often view a claim as "clean" with far fewer elements on it than the payer needs, she says.

"A high percentage of electronic claims are accepted at the payer's doorstep on the first pass," says Lonnie Hardin, executive vice president of operations at Capario, a clearinghouse.

Once it gets into the payer's system, then the payers judge how many of those claims go all the way through autoadjudication.

Wide variations in claims, plan designs, and claim systems make it difficult to glean autoadjudication rates. But there are some metrics available to measure how efficiently payers are processing claims. The annual rankings conducted by athenahealth, Inc., categorize health plan performance in areas such as payment time, denial rate and claim transparency. According to the company, the industry is at an impasse in which providers do not want to change their workflow for a handful of payers, while payers do not want to invest in real-time claim adjudication until they are confident that providers will adopt it.

Aetna did well in the rankings: best among payers for percentage of claims resolved the first time submitted, as well as highest electronic remittance advice (ERA) transparency-reflecting how well the payer adopted the HIPAA 835 standard code set to return claim denials with actionable explanations and clear next steps.

"We did a lot of work to ensure that we are getting the claims in right to begin with," says Eisenstock.

Aetna accomplishes that through automation, by providing better eligibility information up front-anything it can manage proactively to reduce the chances that a claim will stop somewhere in the process.

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