Claims auto-adjudication accelerator

Contributor: Don Canning

When speaking with Healthcare Payer’s Chief Operating Officers on a recent customer listening tour, we learned that many achieve industry benchmark standards roughly between 70-80% for claims auto-adjudication.  Conversely, when evaluating overall satisfaction by large employers, they experience a decreased benchmark by an average of five percentage points, from 64% in 2008 to 59% in 2009¹.

Perhaps the reason for the discrepancies is lack of operational efficiency and to the degree claims auto -adjudication is completed hands-free.  Some interesting assessment patterns indicate that actual auto-adjudication rates are more likely in the 60% to 70% range.  Breakdowns in auto-adjudication processing combined with varying data quality are key culprits causing payers to perform:

• Manual workarounds that cause inefficiencies
• Poor data quality slows claim processing
• Difficulties performing fraud pattern analysis

This causes payers to have a series of manual patch-quilt processes catching claims that fall out of the automated process, ultimately driving costs skyward and slowing down response-time to employers and members.

What’s keeping many COO’s awake at night is their inability to control rising costs, maintaining tight claims management controls and staying competitive – all while raising quality of services and employer’s service satisfaction ratings.  Other c-levels executives are looking towards COO’s to provide upward scalability demanding  high-performance operations that can double or triple membership roles to meet  aggressive growth plans that may include mergers and acquisitions.

For more information about how to improve auto-adjudication benchmarks and data quality preparation read: http://sungard.com/~/media/FinancialSystems/Brochures/Insurance/iWorks_brochure_formworks_august2011.ashx

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¹ http://pwchealth.com/cgi-local/hregister.cgi?link=reg/what_employers_want_from_health_insurers_in_2010.pdf

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