How Well Do You Know Your Data? Is It Costing You Money?
Health plans operate in a complex environment where every claim tells a story. But how well do you truly understand that story? The reality is that inefficiencies in claims processing could be costing you more than you realize.
Start by evaluating key metrics: What is your auto-adjudication rate? What does your PEND ratio look like? How many claims required multiple reviews before payment or were resubmitted for adjustments? If any of these figures seem higher than expected, it might indicate deeper inefficiencies within your claim workflows.
At Emids, we help health plans optimize their core administrative systems (CAS) and streamline data integration, improving both accuracy and speed. By addressing inefficiencies, cleaning up claim workflows, and automating manual processes, you can reduce operational costs and turn potential losses into savings.
The Critical Role of Optimizing Claims Systems
Health plans rely on the expectation that claims, especially routine ones, should flow smoothly through their systems. Stopgaps and protections are in place to flag high-dollar claims or risky procedures, ensuring they receive the necessary scrutiny. However, if routine office visits or straightforward claims are halted, it’s often a sign of deeper issues. Operational disruptions such as incorrect pricing setups, missing modifiers, or misaligned coding may be forcing unnecessary manual interventions.
Read more: Fixing Broken Core Administrative Systems for Future Growth
The key to overcoming these challenges lies in creating a robust coding framework that minimizes such disruptions. Optimizing your claims data flow not only boosts efficiency but also ensures your reporting is accurate and actionable.
The Importance of Visibility in Claims Processing
For a health plan to operate effectively, it needs complete visibility into its claims data, especially for pended claims. Knowing why claims are being held up—for example, due to an incorrect pricing setup or another configuration error—empowers your team to address bottlenecks quickly. The faster you identify and resolve issues, the more operational efficiency you gain.
Automation plays a crucial role here. By automating tasks like report generation and claims processing, health plans can free up resources for more value-driven activities. When manual intervention is required for tasks that could be automated, it drains resources and inflates operational costs.
The High Cost of Manual Claims Processing
Claims processors are often evaluated based on their ability to handle large volumes of claims in a limited timeframe. Their focus should ideally be on reviewing claims for medical necessity. Yet, too often, they get bogged down by routine tasks stemming from configuration errors. This misallocation of time and resources impacts both productivity and costs.
Moreover, many states require that claims be paid within a specific timeframe, sometimes accompanied by mandatory interest rates. A backlog of manual claims can lead to interest penalties, driving up costs even further.
Another common stumbling block is coordination of benefits (COB). For example, if a member holds coverage with another plan but is incorrectly designated as primary on your plan, this can unnecessarily delay the claims process. Rather than holding up claims for lengthy investigations, optimizing workflows ensures quicker resolutions and fewer operational hiccups.
Turn Claims Processing Inefficiencies into Cost Savings
By streamlining claim workflows and optimizing your CAS for efficient reporting and processing, health plans can significantly enhance both speed and accuracy. This transformation shifts potential operational losses into measurable savings.
At Emids, we specialize in empowering health plans to unlock the full potential of their data. Through automation, improved visibility, and enhanced data flows, we help you turn inefficiencies into competitive advantages.
Our comprehensive configuration audit includes an in-depth review of provider contracts, member benefit requirements, configuration settings, and test results. Our team analyzes decisions made during the configuration process to identify root causes of existing issues and deliver actionable recommendations for improvement. We then develop and implement a customized plan to optimize your claim workflow, ensuring greater efficiency and effectiveness.
To learn more about how you can partner with our team to improve your claim workflow and save time and money, contact us today.