Offshore claims processing has traditionally been cheaper than in the United States for obvious reasons-the price of keying in data overseas is a fraction of what it is here. Antares Management Solutions, what's known as a third-party claims administrator that processes claims "under the covers" for major insurance companies, was considering going overseas when it discovered a better solution from GTESS.
Antares was feeling competitive pressure from other companies that sent keying work overseas. Jim Harless, Vice President of Operations, Antares, says, "We're competing with folks who send their work overseas to, say, India where they key and verify every single piece of data just like we do and they'll do it as low as 25 cents a claim. Our average claim-processing costs were four to eight times that, so it was tough in some situations to compete with that offshore keying service."
Harless went looking for a solution that kept the work in the United States yet allowed Antares to be competitive. In addition to the efficiencies of the GTESS technology, one of the benefits he especially liked with the GTESS solution was the fact that he can speak to the production staff and even visit the location where the work is performed if necessary. One of the biggest factors in the use of offshore work is also loss of control. "Once the claim leaves the building," he explains, "a company has very little involvement other than to talk to a service rep-it is not involved with what goes on day to day on the processing floor."
"Under the Covers" Claims Processing
When we submit a health insurance claim, most of us assume the insurance provider processes it and cuts us a check. In fact, many insurance companies outsource claims processing to a supplier known as a third-party claims administrator (TPA) like Antares. Some TPAs even do it under the insurance company's brand. These administrators even outsource part of the claims process to another supplier.
This is the relationship that Antares has created with GTESS for handling dental claims. Antares does "under the covers" claims processing under an insurance company's brand while GTESS likewise is an "under the covers" technology specialist assisting Antares in its services to that end client. So both companies are suppliers to the insurance companies that pay the claims. GTESS processes dental claims and Antares all other claims for the insurance companies with which Antares contracts.
Instead of manual keying as in an offshore operation, GTESS receives the imaged claim by FTP from Antares and extracts the relevant data that Antares would have had to otherwise "key and verify." It then returns an EDI (Electronic Data Interchange) record that Antares can feed into its adjudication engine. GTESS's business process gives Antares faster, more accurate processing and helps lower cost so it can beat out offshore competitors. EDI is the electronic communication of business transactions like claims data in a standard format, in this case in compliance with HIPAA patient privacy regulations.
Out with the Past
Harless explains that processing a claim using key and verify was labor intensive. First Antares scanned the paper claim. Then it gave the paper claim to a claims processor who would do data entry into the adjudications system. The adjudications system judges the benefits the insured person is entitled to and applies them to the processed claim, which determines the amount of the payout. The adjudication system then applies the benefits that that particular member has, based on his or her dental benefits. Then it makes a payment to the provider or the member for that particular service.
The problem was Antares keyed 80 percent of the data fields off one of the many ADA (American Dental Association) forms in the marketplace. Employees entered data fields like the date of service or procedure codes. Then the quality-assurance department stopped as many as 10 percent of these claims for review, according to Harless. Typically another person pulled up the scanned document to make sure that the person who entered all the data keyed the data elements correctly.
Using GTESS's process, Antares now simply scans the paper claims and securely FTPs all imaged claims to GTESS. GTESS first applies the correct Optical Character Recognition (OCR) dental form template and has multiple OCR engines recognize and extract the data to create a second, processable form of the electronic claim. GTESS has almost 500 dental forms registered in its system that Antares would otherwise have to create to speed OCR.
GTESS then applies business rules the buyer and supplier jointly developed to look at claim fields and decide about whether, say, data is correct or accurate. At Antares, a person would have had to make decisions-for instance, to reformat a Social Security number so the claim auto-adjudicates when returned to Antares.
Then GTESS applies provider (dentist) and member (patient) filters to insure the data in these claims sections is correct and formatted. Otherwise someone at Antares must manually do it to enable adjudication.
Finally, GTESS formats the claim in an 837 HIPAA-compliant EDI format and then and returns it to Antares for auto-adjudication.
The especially crucial arrow in GTESS's quiver is its exhaustive business rules that govern how it treats data in fields. Usually a company like Antares has to develop rules from scratch. Or, if it's using commercial OCR software, the software vendor charges to develop appropriate rules. This is called "registering" and could be very time consuming and therefore costly. Often the vendor is not a specialist in healthcare and a buyer like Antares has to educate its programmers to help build the rules. Harless says Antares had experimented with these methods in the past with little success.
GTESS, by contrast, "already knew each and every box on the claim form and the issues associated with them. It had written various business rules for them, knew how they were commonly applied, and asked us which ways we preferred to have them applied," Harless says.
The GTESS system is also almost completely automated. The only time a claim goes to a person at GTESS is if they don't get a perfect match to tables of possible data fields or an unclear character, according to Harless. When this happens, GTESS has an exception-processing routine where a manual review and decision-making process occurs. At this point, someone identifies, say, a difficult-to-read character and makes a decision about its correctness.
To speed throughput and simplify decision-making, no one person sees the entire claim. Instead it's broken into segments; for instance, someone examines the provider section, someone else the line-item detail, and a third person the header record. Less than five percent of claims require exception handling.
In doing quality assurance of GTESS's performance, Antares routinely examines claims batches. On average a batch of 400 documents with 100 characters in each yields one or two data errors. That superlative accuracy dramatically expedites auto-adjudication. Even with keying and quality assurance Harless admits he would be hard pressed to surpass that level of accuracy.
The addition of the GTESS process has allowed Antares to be more price competitive too, which has allowed it to keep its business in the United States. "We can now compete much better on price with those competitors that use low-cost keying overseas in their service offerings," says Harless. "With GTESS as a business partner, we feel that the application of technology gives us a competitive solution."
Lessons From The Outsourcing Journal:
- Outsourced key to verify work for healthcare claims processing abroad can cost eight times less than in the United States, so the only way US claims-processing companies can compete is with more efficient technology.
- A supplier with appropriate OCR forms and business rules for the specific healthcare claims being processed can radically expedite processing and improve quality.
- Keeping claims processing in the United States also helps maintain control over personnel and business processes. Managers can interact with production staff and visit the worksite.