Technology plays a major role in claims processing

By John Andrews
12:00 AM

IF ANY AREA IS emblematic of the paper overload that exists in healthcare, it’s claims processing.

    While many cling to their paper, software vendors contend that conversions to automated systems happen regularly and claims are being paid faster as a result. Even so, for fraud monitoring firms like Sandy, Utah-based Healthcare Insight, the transition from paper to cyberspace isn’t easy.

“The technological advances that have occurred since 1997 have both helped and hurt,” said CEO Barry L. Johnson, DDS, whose company reviews electronic claims for the insurance industry. “When you create a paper claim someone has to enter it and there is multiple repetition and work. But more electronic claims submissions means more adjudication without human oversight. In essence, some of the advances to facilitate claims have facilitated fraud.”

    The health insurance industry estimates losing $60 billion to $290 billion a year to fraud and $30 billion to $60 billion from abuse. The National Health Care Antifraud Association suggests these figures represent between 3 percent and 10 percent of total annual healthcare expenditures.

    Johnson’s firm works on the payer side, after claims are adjudicated. The evaluation system scans claims for outliers that don’t make sense.

“We reject anything that stinks,” he said. “We report that information electronically to clients and they accept or reject the recommendations.”

    Claims processing has become much more efficient as providers switch to electronic formats, agreed Dawn Burriss, vice president of the TriZetto Group, a Newport Beach, Calif.-based firm that provides software and services to health plans. Still, provider identification numbers slow the process, gumming up the flow as payers try to sort out the discrepancies.

Costs, Reimbursement

Providers sometimes run into communication snarls regarding claims, especially with pharmacies.

    “It has been a challenge because pharmacy is typically so focused on patient care they haven’t funded the billing position – it’s either a secondary function or they don’t put the right resources into it,” said Mary Beth Lang, vice president of total spend analytics for St. Louis-based Amerinet’s Diagnostics division.

    By collaborating with Scottsdale, Ariz.-based Craneware, Amerinet has a system that connects the pharmacy’s contract price with reimbursement. Amerinet manages supply contracts with pharmaceutical and medical vendors, while Craneware offers a Chargemaster tool that provides an infrastructure for price and reimbursement tracking.

Data tracking

Data can hide inside a claim, and without the proper hunting tools billing staff can get “lost at sea” trying to find it, said Scott Blau, CEO of Tarrytown, N.Y.-based Datacap.

    But while claims come in different shapes and sizes, it is possible to develop algorithms that can key on certain data characteristics, he said. The company’s Taskmaster 7 does just that, using a rules engine that can navigate the page and locate the key information.

Recouping lost dollars

Difficulties with ER nursing assessments cost Coffee Health Group in Florence, Ala., an estimated $30,000 a month. Since the group had no designated employee entering the coding for the ER, codes for the thousands of nursing assessments that occur each day were often done improperly.

    “We didn’t have the right process in place,” said Ben Bowling, interface/internet specialist for the organization. “Nurse assessments were frequently misrepresented.”

    Using Boston Software Systems’ WorkStation platform, Bowling and his team generated a spreadsheet of billing codes for ER nursing assessments. Every assessment is posted each night, with the spreadsheet time-stamped for validation. In order to be billed correctly, patient charges must be posted on the same day. Automating this process ensures that a complete, accurate batch posts each night.