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What Technologies Support Payers With Claims Management Processes?

Claims processing software, adjudication software, and health IT systems can streamline the claims management process for payers.

Victoria Bailey
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Published: 17 Oct 2023

Claims management is an integral part of the healthcare process as it determines how much providers receive in reimbursement, what costs health plans will cover, and what patients ultimately owe for their care.

After providing care, healthcare providers must code the services and submit a claim to the patient’s health insurance plan. Once they receive the claim, payers review and process the claims to determine if they cover the services provided, known as adjudication.

Payers can pay the claim in full, deny the claim, or reimburse providers for less than the claim requests. In some cases, payers may determine that the billed service level is inappropriate for the diagnosis or procedure codes, leading to a rejection or a lower payment.

While providers should prioritize ensuring their claims are error-free and coded accurately before submitting them, payers must verify the completeness of claims, confirm patient coverage, and identify potential fraud during their reviews.

Leveraging various technologies can help payers efficiently manage, process, and adjudicate healthcare claims.

Claims processing software

Claims processing software can automate tasks to help payers receive, validate, and process claims. Payers may use multiple software solutions to streamline the process. Claims processing software can include solutions that gather data, produce estimates, analyze claims, automate communications during the claims process, and support claims processing workflows.

These technologies often provide risk assessment capabilities to identify claim complexity and analyze data to detect fraudulent or duplicate claims. In addition, claims processing software checks claims for completeness, accuracy, and compliance with coding standards.

Claims adjudication software

Payers can use claims adjudication systems to assess claims for medical necessity, coverage, and contract agreements. This software often includes capabilities to automate workflows for claims adjudication, auto-adjudication, benefit administration, enrollments, and premium billing.

Additionally, claims adjudication systems can offer interoperability functions and automated re-adjudication capabilities to streamline claim reprocessing. Depending on the vendors that payers partner with, claims adjudication software can provide customized claims management, medical records management, and patient coverage verification services.

Health information technology

For payers to properly adjudicate claims, they must determine medical necessity. Health information technology (IT) is essential for this process as it allows payers to access patient medical records. With access to health IT like electronic health records (EHRs) and personal health records (PHRs), payers can be more familiar with a patient’s medical history. Health information exchange (HIE) platforms can facilitate the sharing of this data between payers and providers.

While many providers have automated their claims submission process, some still submit paper claims to health insurers. In such cases, payers may implement tools to transform information in paper documents into a format that health IT systems can read and organize. Optical character recognition (OCR) can help convert paper claims and other documents into electronic data that automated systems can process.

Machine learning & artificial intelligence

Payers can use machine learning and artificial intelligence (AI) to increase efficiency in several areas of claims management. Algorithms can help identify patterns of potential fraud, waste, and abuse, in addition to flagging claims that may need further review.

AI systems can assist with determining medical necessity by analyzing claims data against established medical standards. AI can also help predict claims likely to be denied by analyzing historical data and claim patterns. This can enable payers to proactively address issues and improve claim acceptance rates.

Key claims management vendors

Partnering with vendors and outsourcing claims management tasks can reduce administrative burden for payers and speed up the process.

Zelis is a common vendor payers use for claims management—the organization partners with over 700 health plans and processes over $200 million in payments each year. The vendor offers payment integrity services, B2B payment solutions, and claims communication solutions.

According to the Payer Claims & Administration Platforms 2023 report from KLAS, payers value efficiency and functionality in their claims and administration vendors.

Among 28 payer organizations, 14 considered using HealthEdge’s claims and administration solutions, with the vendor receiving an overall performance score of 76.5 on a 100-point scale. HealthEdge users said the platform improves automated adjudication rates and offers solid capabilities for benefit configuration and processing claims.

Twelve organizations said they would consider using Cognizant, which received a 74.7 for overall performance. Payers using this vendor reported satisfaction with its ability to manage multiple business lines and said functionality and efficiency improved over the years.

Provider-sponsored health plans often use Epic for claims and utilization management services due to its integration capabilities and customer loyalty. The vendor received a 79.0 for overall performance, the KLAS report found.

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