Past, Present and Future of Medical Claim Processing
Claims Processing is the part of the revenue cycle where claims for reimbursement sent from a provider to a payer are taken in, verified, and paid (or denied).Many fraud cases had been caught in past few years. Time has changed and new techniques, terminology are coming up to make the things for easier and look better. In the same way let's discuss how the Claim Processing Service process has faced many changes as the time was moving: The Past: Historically, HCOs had few tools for uncovering fraud and most of them did not involve analytics. Along with tips from law enforcement, outlier models and business rules, HCOs relied heavily on claims adjusters to spot anything suspicious. But keeping adjusters up to date on the latest fraud schemes requires ongoing training. Also, in order for a claim to qualify as fraudulent, you must prove in court that an intent to deceive for the purpose of financial gain existed. Less than 10 percent of the money lost to fraud was ever recovered this way. What’s more, fraud accounts for only a fraction of the total loss due to billing errors. According to Stone-gate Advisers, in the US alone, payment integrity issues point to a staggering $800 billion in health care losses each year. That’s why many HCOs are moving away from the pay-and-chase model. Now, they are looking beyond the claims department and taking an enterprise-wide approach to spotting errors, abuse and waste throughout the entire claims process. The goal is to spot fraud and billing issues earlier in the cycle and stop losses before they occur. The PRESENT: Now a days new technologies cover a broad spectrum of behavior from organized crime to simple mistakes in filling out a form to eligibility fraud. They also cover subrogation, where another company is responsible for a piece of the claim – for instance, an auto accident where liability should be split between the medical insurer and the auto carrier. A key enabler in payment integrity is data-driven analysis. New Techniques can quickly search though unstructured textual data in claims. They can mine through electronic medical records, call center logs and information from provider offices. can also analyze third-party data and point to possible collusion – for example, a doctor’s office making large purchases from a medical supply store it also owns. They can provide insight into complex schemes that are difficult or impossible to understand with traditional techniques. The Future: Why are new developments so important? Because they play a key role in helping HCOs contain their costs. Since the Affordable Care Act (ACA) passed in 2012, insurers have had to price plans in a way that keeps customers happy yet still produces a profit, albeit a thin profit.They include a number of strict regulations that put tremendous pressure on HCOs to reduce costs. For example, the act requires insurers to pay out that 80 to 85 percent of premiums on claims. That leaves only 15 to 20 percent left for administration and profit.Many insurers are merging in an effort to gain the benefits of size and scale to help manage costs. At the same time, HCOs are competing on public exchanges. The ones that survive in the new world will be those that can trim waste to offer the most competitive rates.
