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Insurance Claims

Even with software, insurance claims management can be a laborious and tricky process. Notably, the persistence of filing errors and the risk of fraudulent claims force payers to exercise caution during claims adjudication and authorization.

In the United States alone, fraudulent claims result in economic losses of about USD 308.6 billion each year. While fraudsters often reason that only insurance companies lose, the fact is that regular consumers bear the brunt of the effects through higher premiums.

Unfortunately, this all makes claims administration an expensive and time-consuming process. In areas like health insurance, these delays in claims processing could lead to serious problems for insured parties. To improve claims administration, more insurers are updating their health insurance solution to streamline processes and reduce costs without negatively impacting outcomes.

Here are the four elements of an empowered insurance claims administration core system:

Simple, More Streamlined Claims Pricing

For insurance companies to maximize revenue, it’s necessary to offer as many payment options as possible. Having options makes it possible for more individuals to buy policies while also increasing the chances of them paying their premiums on time.

Today’s health insurance solutions support a wide range of pricing and payment methods, including ones that are tied to financial instruments and external markets. This flexibility in claims pricing gives payers the ability to continue providing service and generating revenue even with current challenges in the healthcare insurance market.

Frictionless Claims Adjudication

The speed at which claims adjudication can be performed has a major impact on the quality of service delivered. However, claims adjudicators typically have to look at an extremely wide set of details before they can make a decision, slowing down the process. In healthcare, such delays are almost always problematic for policyholders.

Thankfully, updated health insurance solutions can reduce the time it takes to complete adjudication by applying a wide set of smart automation features. For instance, new systems allow for real-time processing—a departure from the time-intensive batch processing typical of adjudications. Custom process automation scripts can also be implemented to ensure that manual data entry and retrieval are minimized, allowing adjudicators to reliably verify more claims in a shorter period.

Importantly for healthcare, new systems are also capable of automatically adjudicating cases, reducing the need for human intervention and increasing service levels. These systems can also alert adjudicators to various red flags that indicate potential claim issues, from duplicate entries to possible instances of fraud.

Importantly for these platforms, each claim could be analyzed and sorted even before a human adjudicator works on them, improving decision accuracy while effectively increasing the number of policyholders that could be served.

Transparent Product Definitions

Insurance products today are increasingly sophisticated. This is a natural consequence of the ongoing efforts of insurance businesses to deliver highly customized care at good prices. However, this abundance of choice has often made things confusing for insurance personnel, healthcare workers, and policyholders. Making the appropriate decisions isn’t always straightforward, given the number of details, insurers need to look at.

Improved health insurance systems offer more transparency and customization for product definitions, allowing benefits to be easily defined and understood. Benefits could be defined in ICD, HCPCS, CPT, CDT, NDC, and other international healthcare code sets, and custom cost-sharing models could easily be set up.

Additionally, new healthcare systems can simplify policy renewals by keeping parameter definitions separate from parameter values, reducing the potential for human errors and processing delays.

More Efficient, Integrated Authorizations

Authorizations are crucial for the delivery of modern-day insurance and non-emergency healthcare. An authorization is a medical necessity review that ensures policyholders receive care that is both effective and does not include unreasonable prices or risks.

Unfortunately, authorizations can take a significant amount of time to complete, particularly if the policyholder has a complex case, is undergoing an expensive procedure, or is being treated for a condition that may be in a gray area of their coverage. A lot of paperwork often has to be filed before authorization is granted.

Current-generation insurance systems can automate many of the tedious aspects of the authorization process. Contemporary insurance software usually includes extensive authorization and referral management features, offering near-unlimited freedom when it comes to approving medical procedures. The data integration capabilities of these systems also allow a much clearer view of the requested procedures than would have been possible on legacy platforms.

Supercharge Your Claims Process Today

Current health insurance business models are no longer sustainable due to the rising cost of healthcare. Yet, health insurance remains a basic necessity. To enable better service without putting policyholders at risk, a review of claims processing platforms has to be made.

By improving claims administration, not only will insurers be able to reduce their risks from fraud and errors, but they can also vastly reduce their overheads and find new sources of revenue. Best of all, they can significantly improve the claims experience for policyholders. This all makes updates to claims systems well worth exploring.

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