Consumerism fuels fire for real-time claims adjudication

March 1, 2007

With the increasing trend toward consumer-directed healthcare, providers can add another specialty to their list: bill collector.

WITH THE INCREASING trend toward consumer-directed healthcare, providers can add another specialty to their list: bill collector.

Those slow payments and non-payments cause a cash flow problem that real-time claims adjudication (RTCA) could solve.

In today's world of electronic payments, consumers expect to know what something costs ahead of time and pay for it immediately.

The sea of change will be led by larger health plans such as Humana, Blue Cross and Blue Shield and United as they execute real-time transaction in demonstration models, says IDC's Young, however, she agrees that the change will be fed by the trend toward a consumer health plan strategy.

Physicians now have to manage direct consumer payments and insurance claims. The systems and technology to bill directly at the point of care are not universally implemented. Many providers use third-party billing companies who execute claims to insurance companies in batches, not in real time. Because each provider usually deals with multiple insurance companies, the challenge of determining what each plan pays is daunting. There isn't a universal way to exchange electronic financial data in healthcare the way there is in retail.

"Assuming someone could get beyond the issues on the provider side, now we get into health plan technologies," says IDC's Young. "Many use multiple legacy applications not suited for handling real-time processing. It's difficult, when multiple systems need to 'talk' to each other, as it were, to get a real-time response. It's not that they can't. Auto-adjudication rates [adjudication without human intervention] have been increasing to where 68% to 70% of claims are automatically adjudicated now, but that doesn't mean they're done in real time."