Electronic Payment Key to Streamlining Healthcare Claims Management

The complexity around healthcare claims management is a major pain point for provider organizations, big and small. The increasing cost of claims coupled with a complex system of many payers, each with their own rules and requirements, creates administrative burdens and obstacles for providers. Ultimately, this complex system impacts the patient experience, as patients must wait on payers and providers to process claims to send them a bill.

Payers and providers alike have turned to digitization to streamline the healthcare claims management process. Electronic adoption of claim submission, attachments, coordination of benefits, and other parts of the claim process has increased significantly over the last couple of years, and to great benefit to providers.

The Council for Affordable Quality Healthcare, Inc. (CAQH) recently reported that the healthcare and dental industries have avoided $122 billion in costs by streamlining administrative functions, many involving the claims management process. In addition, providers have saved countless time and resources by adopting electronic approaches to claims management, CAQH found.

But more efficiencies and savings can be realized. CAQH estimates that payers and providers could collectively save another $16.3 billion by fully automating nine common transactions, including claims payment and remittance advice.

The first step: Understanding electronic claims payment and ERA

The first place to start to realize savings and efficiencies is claims payment and remittance advice, says Alasdair Catton-Chastain, Senior Manager, Provider Experience at Zelis.

“If you want to get paid electronically, anyone can set that up. It’s pretty basic knowledge: You give your banking information, you get the money routed to the bank, and maybe you can access a portal to pull down remits that you would normally get in the mail,” explains Catton-Chastain, who oversees provider implementations.

“Where it starts to get difficult is understanding how electronic remittance advice might be imported into your system.”

Healthcare providers typically use multiple revenue cycle management and other health IT systems for claims management. Additionally, many providers rely on their EHR system to handle many of the administrative tasks associated with getting paid. But this patchwork of technology is contributing to the problem of claims management digitization, rather than helping to move the needle with electronic remittance advice (ERA) adoption.

“Some providers may not understand the complexities of the software that they currently have,” Catton-Chastain states. “Sometimes, it is an additional functionality, which is not included with their service pack. It can also be an additional fee to turn on the ERA module. Other times, it’s the system that is outdated because perhaps providers purchased 20 years ago, so the system doesn’t support the ERA coming back in.”

Just as common though is a knowledge gap, according to Catton-Chastain.

Understanding a claim, including what got paid by payers, how much was paid for each claim line versus what was billed, and payer explanations, is a top challenge of healthcare claims management. Remittance advice contains highly detailed, complicated information that, when sent in paper form, must be transcribed fully and accurately in order for providers to send timely, correct bills to patients.

Receiving remittance advice electronically can improve the process and reduce the risk of human error. However, the current state of ERAs leaves much to be desired and possibly cash on the table.

While electronic claims payment may seem like a simple task, providers typically have to enroll with each of their payer partners. Payers tend to operate their own claim portals to digitize claims management. For providers, this means enrolling and logging into each portal separately to retrieve critical payment information, including ERAs. They must then transport that information to their own billing systems.

“Sometimes with ERAs, some of them are not going to be understandable. Some payers use proprietary codes from their own adjudication systems, for instance,” Catton-Chastain explains. “They may have to revert to the paper remit to verify what was actually paid. Then, if they still can’t find the correct information, they need to call the payer.”

Time is of the essence in healthcare, especially as patients act more like regular consumers.

“The quicker you understand what you’ve been paid versus what you billed, the quicker you can put in a claim for secondary insurance or send out a bill to the patient for their responsibility,” Catton-Chastain says.

A solution for electronic payment, ERA

Another IT system for claims management may not be appealing for providers who have already invested capital and resources into legacy systems. Consolidating IT systems after a merger and setting up patient billing can also be off-putting just because of the upfront costs, Catton-Chastain explains.

However, a truly digital claims management system can bring together payers and providers to not only streamline the management of claims but the technology behind electronic payment, remittance advice, and other necessary functions.

A singular point of contact for ERA and claims payment is key to streamlining healthcare claims management and reducing the burden of working with multiple payers. A solution that enables providers to enroll and view claims from across their payer partners allows them to access payments and information faster to ultimately help the patient faster. Providers also have one place to communicate with payers in this multi-modal payment environment.

These solutions should also deliver increased security versus managing multiple portals with different credentials and security systems. A secure solution can also integrate with existing IT and billing systems to save providers time and the extra cost of implementing more software.

An integrated solution means ERA and other data translate to the proper systems and patient accounts. For office staff, it also means less time on administrative tasks that do not add value to the overall patient experience.

While a digitized, end-to-end claims management experience is not yet a reality for most providers, some are tapping into the technology to streamline the entire process and deliver value to patients. A multi-modal, secure solution can enable providers to not only realize potential savings from automation but get paid quicker both by payers and their patients.

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Zelis harnesses data-driven insights and human expertise as scale to optimize every step of the healthcare payment cycle. We partner with more than 700 payers, including the top-5 national health plans, Blues plans, regional health plans, TPAs and self-insured employers, 1.5 million providers and millions of members, enabling the healthcare industry to pay for care, with care.