Automation and AI are at the forefront of improving efficiency and accuracy for payers. One of the areas where these technologies hold promise is in advancing the application of claims edits. Claims editing is vital for payers as it significantly impacts cost control, regulatory compliance, and operational efficiency. Accurate claims editing prevents overpayments, ensuring financial stability in a complex healthcare system. It also keeps payers compliant with evolving regulations, reducing legal risks. In a competitive market, advanced claims editing provides health plans a crucial edge in delivering a superior provider and member experience and maintaining a competitive advantage.
Administrative costs associated with insurance and billing-related activities divert valuable resources from patient care. However, creating new efficiencies in claims management and reimbursement can help redirect those funds back to patient experience. Of the $4.5 trillion spent annually on healthcare in the United States, administrative costs associated with health insurance processes, such as eligibility, coding, submission, and rework, account for about 15 percent, according to the Commonwealth Fund. Additionally, the administrative burden on providers, including general administration, human resources, and quality reporting and accreditation, represents another 15 percent of the excess.
Improving claims editing can address these inefficiencies and reduce administrative burdens. By adopting best practices, such as leveraging automation and AI, enhancing data accuracy and maintaining transparent communication with providers, payers can streamline their claims processes, improving care costs and ensuring optimal outcomes for providers and members.
Embracing technological advancements
Claims editing has evolved significantly, with a strong emphasis on leveraging automation, AI, and machine learning to enhance accuracy and efficiency. This shift from manual, source-based edits to data-driven approaches highlights the importance of adopting advanced technologies in the claims editing process. Advancements cover not only content generation but also the execution of edits through automated systems and the use of AI, including generative AI and machine learning.
The market is making significant investments in these technologies to develop more robust and efficient solutions to streamline processes, enhance accuracy and reduce the need for manual reviews.
"Industry leaders started using automation a few years ago, initially employing web scrapers to identify changes in regulatory guidelines, followed by manual reviews," says Kelly Romsdahl, strategic product leader at Zelis. "Now, we are streamlining these processes by downloading and comparing documents, with human reviewers ensuring readiness for integration into the claim edits. Over the last few years, they have been enhancing this approach and seeking new tools to automate all steps, reducing the need for manual review."
Payers should embrace technological advancements to improve the efficiency and accuracy of their claims editing processes by using data-driven approaches to identify anomalies and opportunities not possible with document-based edits. "It's a shift from solely using source documentation to leveraging data to generate value," notes Craig Van Natta, vice president of claims edits operations at Zelis.
Balancing automation with human expertise
While automation and AI are essential for improving claims editing, human expertise remains crucial. The integration of these technologies should be balanced with skilled professionals validating and fine-tuning automated results to ensure accuracy and compliance.
"In the past, people manually performed claims editing. In the future, AI and automation will take over these tasks," Van Natta explains. “This shift will require claims editors to operate and ensure the accuracy of these automated tools, as they can still make errors. During the transition, human validation of AI and automation results will be crucial."
The role of claims editors will evolve from performing the work to overseeing and validating the automated processes to ensure accuracy.
"Automation is great, but personnel with medical coding backgrounds is still a must," Romsdahl emphasizes. "We still validate what automation pulls together in terms of codes or edit relationships. Our combined years of experience allow us to easily identify discrepancies that might stand out to us but not to a program. Our familiarity with code relationships allows us to fine-tune the results beyond what an automated system can achieve.”
Health plans must balance automation with human oversight to maintain accuracy and effectiveness as they automate, leveraging skilled professionals to validate and fine-tune automated processes.
Enhancing provider relationships
Effective claims editing involves clear communication and education to reduce friction between payers and providers. Payers must develop clear and transparent dispute processes, educate providers on why edits occur and how they work, and maintain open communication lines to keep providers informed about changes and updates.
"To work well with providers, it's essential to establish a clear and straightforward dispute process for those who disagree with edits. The right claims editing partner often does this on behalf of clients if needed," says Van Natta.
"Education is also crucial," he continues. "Investing in teaching providers why an edit occurs, how it functions, and when it will happen helps avoid surprises. Combining transparent recourse processes with thorough education sets clear expectations for the claims editing process, fostering better provider relationships.”
Health plans should clearly explain denials with detailed response letters, leverage experts for quality responses, and maintain transparency in the claims process. They should adopt a consultative approach, aligning with payer policies, customizing solutions, and emphasizing strong customer service. By keeping communication open and addressing provider concerns promptly, payers can build stronger relationships, reduce friction, and enhance overall payment integrity and efficiency.
Navigation compliance, customization and consolidation
According to Van Natta and Romsdahl, payers must prioritize staying compliant with regulatory changes, differentiating through customized services, and navigating market consolidation carefully to ensure operational efficiency, maintain strong client relationships, and foster innovation.
Payers should implement robust testing processes to ensure updates and changes do not disrupt existing operations. They should also use automated tools to stay up-to-date with regulatory changes and ensure edits remain compliant. Likewise, they should collaborate internally to stay informed about regulatory updates and communicate these effectively to clients.
To differentiate themselves through customization and service, health plans need to offer customized edits tailored to specific client needs and sensitive provider relationships to add value and reduce friction. They should highlight the benefits of handling disputes on behalf of providers and providing additional educational resources. Those who recognize the importance of a white-glove concierge approach will build strong client relationships and ensure satisfaction.
Given vendor consolidation in the healthcare industry, payers must understand the implications of industry consolidation, including standardization and reduced competition. They should evaluate solutions based on their ability to innovate and provide value beyond what larger, consolidated players offer. Payers must consider the impact of fewer choices and competitive pricing on their operations and make informed decisions accordingly.
Conclusion
Effective claims editing is essential for payers to control costs, comply with regulations and improve operational efficiency. By leveraging automation and AI while maintaining human oversight, payers can enhance accuracy and reduce administrative burdens. Clear communication and education with providers, along with customized services, foster stronger relationships and reduce disputes. Navigating market consolidation with a focus on innovation and value ensures a competitive advantage. By adopting these best practices, payers can optimize their claims editing processes, redirect resources to patient care, and achieve better overall outcomes.
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About Zelis: Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts. To learn more about how Zelis can help improve payment accuracy, click here.
