Claims submission ASP model a hit with insurers

By Patty Enrado
12:00 AM

Direct payer-to-provider connectivity is on the rise among even smaller providers, but analysts say that clearinghouses will not be going away anytime soon.

The latest example of expanding payer-to-provider claims processing connectivity comes courtesy of Harvard Pilgrim Health Care, based in Wellesley, Mass. and Plano, Texas-based Perot Systems. Using Perot's open-architecture Web services model, Harvard Pilgrim is now offering smaller physician groups and clinics the same transaction-processing functionality it has supplied to 21 larger provider groups for the last five years. Harvard Pilgrim, which serves approximately 800,000 members, says the lower costs associated with Web services makes such connectivity more feasible.

John Kelly, business architect for Harvard Pilgrim's channel strategy, said that the scalable business-to-business system will change the role of clearinghouses.

"While certain providers will still want to deal with clearinghouses, clearinghouses will need to expand and innovate," said Kelly. "A hybrid market for transactions will emerge. Leveraging new technology that adds value will appeal to payers and providers."

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Matthew Kristin, chief architect for Perot Systems, said the direct relationship between provider and payer opens new avenues such as real-time syndication.

Kelly noted that the Web services tool, which is processing several thousand transactions per week, is part of a set of services that Harvard Pilgrim Health Care is offering.

"We want to sell the concept of direct business, a complete solution set for providers and payers," said Kelly.

Eric Brown, vice president of healthcare and life sciences for Forrester Research, sees the real opportunity in payer-provider connectivity when a business-process outsourcer manages both sides of the transaction.

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