Making Medical Claims More Accurate | Article

outsourcing medical claimsInsurance claims processing is a major concern within the healthcare industry. Since billing and collection fees can cost a healthcare agency between six and 15 percent of the total fees collected, and disputes often arise between the patient and the insurance company, many organizations are looking for ways to reduce costs and increase claims accuracy and efficiency. That’s why Indianapolis, Indiana-based Healthx, Inc. turned to Earth City, Missouri-based Advanced Business Fulfillment (ABF), Inc. for outsourced claims information technologies.

Healthx is a healthcare eServices company that makes healthcare information more accessible to customers. “We take data from an insurance claim and use ABF’s claims information technologies to put that online with a secure link to the actual image that went out in the mail. It helps to settle disputes, and it makes customer service more timely and secure,” says Bob Carlson, vice president of sales and marketing at Healthx. “It’s a real benefit to be able to see the exact document that we send out,” he adds.

Resolving Disputes Faster

The biggest benefit of outsourcing claims information technologies, says Carlson, is the amount of time saved researching a disputed claim. Eligibility errors are the number one reason that claims are denied or errors are made on claims, and Carlson says this method of having the actual image of the claims information makes dispute resolution a more efficient process. “Our clients see a reduced number of phone calls because the payee can see the information online. In dispute resolution, the client is looking at the actual image that was sent.”

Customer disputes are also more easily resolved, says Carlson, because the agent answering the call knows exactly what the customer got in the mail. The customer, or payee, is put at ease knowing that the insurance provider will always have that image and have immediate access to it.

Additionally, of the roughly 5 billion healthcare claims that are filed annually, only about 1.75 billion of them are paper-based. The remainder are based on electronic data interface (EDI) technologies. And, ABF is positioned to make that EDI-based claims processing more efficient by partnering with all of the major healthcare EDI providers.

According to DiMartini, the process of claims communication is almost the same in every insurance company. That makes offering automated claims information as simple as partnering with the 15 major software companies that already provide claims processing software to insurance companies.

“Since the software for one of those fifteen companies is already on the company’s computer,” he says, “we can outsource an entire call center in just a few hours by having the software vendor turn on a flag that creates a raw data file, which is sent to us. Then we can incorporate that information to the services we provide to our customers. We’re linked to each of those vendors through a standard interface.” And that standardization makes processing claims even simpler-“almost brainless”-he says.

Business Considerations

It is not as simple as just flipping a switch, however. DiMartini says that the automation process is determined by business rules that the buyer has to define. Therefore, he says, it’s essential for an organization to understand what its needs are before trying to implement an outsourced claims information service.

Additionally, says Carlson, “Because this is fundamentally a technology project, someone within the organization needs to coordinate the implementation. And because healthcare information is guarded by the U.S. Health Insurance Portability and Accountability Act (HIPAA),” he says, an organization needs to ensure that its claims information outsourcer is HIPAA compliant.

ABF’s products move toward HIPAA compliance, and its products are implemented into an organization’s normal business workflow. “ABF provides us with a unique set of capabilities,” says Carlson. “It’s the best of both worlds, and the reason we’ve chosen them is because our market asked for it and because it makes the company’s own business processes flow smoother.

According to industry analysts, automating claims information and processing can save the healthcare industry more than $125 billion. That’s more than half of the administration cost of processing those claims.

“Where the market sees value and synergy,” says Carlson, “you can push for it with a service like automated claims information and get a better solution that increases efficiencies and decreases costs.” And, he says, that is exactly what outsourcing claims information to ABF has done for Healthx and its customers.

Lessons from the Outsourcing Journal:

  • Billing and collection fees can cost healthcare organizations between 6 and 15 percent of the total fees collection, but automating claims information outsourcing can reduce that cost by about half.
  • Outsourced claims information is the process of digitizing healthcare and insurance claims information.
  • Automated claims information solutions should be built around existing organizational business processes and needs.
  • Approximately 3.25 billion claims are filed annually by electronic means and effective processing of those claims could yield a marketwise savings of over $125 billion.


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