Modernizing medical billing and claims processing

Healthcare billing and claims administration constitute approximately 3 to 4% of the revenues for payers and providers. As the second-largest source of administrative burdens and expenses in the US, they cause the US healthcare system to cost more than other countries. Thus, reducing these costs has been one of the key administrative priorities in the healthcare industry for a long time. These costs are driven mostly by the complexity of prevailing coding, billing, and adjudication processes, variation across providers and payers, and continued reliance on manual input and review. The cost drivers also result in significant time delays for patients and compliance issues. 

Real-time claims processing is estimated to save at least  USD 40 billion a year given that billing and insurance related administrative costs are estimated to be over USD 150 billion in the US every year.

Challenges with current claims and billing systems

The monolithic nature of current state legacy claims systems poses significant challenges making them ineffective to meet the new business models as well as compliance and regulatory needs.

• Monolithic legacy system- Most payers have home-grown claims adjudication systems that combine benefits, membership eligibility, provider contracting, and hard-coded business rules
• Batch processing- Most payer claims systems, clearinghouses, and EDI gateways function in batch architecture with many hard-coded business rules in each layer
• Complex terminology/code sets- Healthcare regulatory and compliance mandates continue to evolve including codes like ICD10, HCPCS, and CPT. Upgrading and addressing these requirements become complex
• Testing complexity- Testing of claims systems is inherently complex due to monolithic structures
• Hardcoded business rules- Hardwired business rules for payer claims with no visibility and transparency
• Administrative burden- Lack of cloud-based claims processing creates a significant administrative burden for the providers along with account receivable delays
• Inaccurate coding- Coding inaccuracies lead to claims denials, healthcare billing, payment, and collection issues

Expectations from the modernized claim processing

The healthcare industry is under immense pressure to leverage and deliver digital capabilities across the entire claim process. To win customers and reduce operational costs, payers must target core systems that are simple, modern, and digitized. This means adopting solutions and all-in-one platforms that are adaptable and help in streamlining claims management—and in turn, providing a better customer experience.

Over the next decade, next-generation Artificial Intelligence (AI) capabilities have the potential to completely transform the claims process.

Transforming provider experience through real time claims submission and digital payment settlement.

The monolithic nature of the current claims systems poses significant challenges, making them ineffective in their ability to meet the changing demands of the patients, health plans, and providers. Real-time claims submission from electronic medical records (EMR), clinical records using AI/ML-driven auto coding offers the potential to significantly reduce the costs while improving the overall payment cycle turnaround times for providers and health plans. Plan providers looking to transform the provider and member experience need a real-time claim processing system comprising of the following.

• Cloud-native platform and modern delivery models
• Core-native fast healthcare interoperability resources (FHIR) repository and extensive interoperability using FHIR APIs
• Rules-based engines that are highly configurable to accommodate ever-changing regulatory needs. Reusable rule components that process transactions in real-time and can dynamically support customized offerings (benefits, provider contracts, and more) through configuration
• Support for changing business models such as value-based care and other payment models
• Support for microservices-based architecture with pre-built interface libraries enabling faster enterprise integration
• Modularized solution with decoupled business functions to enable flexible implementation and best-of-breed component selection. Data and analytics foundation to support value-based models, quality performance incentives, bundled payments, and shared risk calculations

Envisaging healthcare industry with HCLTech cloud-native real-time claims processing

HCLTech is applying its cloud technology and healthcare industry expertise to build a healthcare platform with a retail-like experience. The platform is aimed to be leveraged for healthcare claims wherein processing time can be reduced from 5 days to 10 seconds.

Figure 1.Real-time claims processing solution architecture

Real-time claims processing solution features

1. Healthcare data interface engine

   FHIR-based EMR integration engine enables real-time and secure integration across multiple data formats including DICOM, FHIR, and HL7v2. The integration engine is powered by HCLTech’ deep domain expertise across payer and provider core business operations and multiple EMR vendor partners including Cerner and Epic

2. AI/ML coding engine

   AI/NLP-based digital coding engine that  translates the information in the EMR physician notes into accurate, usable medical code to create ‘superbill’ with ICD10, CPT, and HCPC codes. The scale bioinformatics analyses pipelines API, variant transforms, and ML-based tools like DeepVariant.

3. Native FHIR repository

   Persist all the clinical data and physician notes in a native FHIR repository which can render the data instantly to all the peripheral surround systems using FHIR API’.

4. Business rules engine

   EDI X12 HIPPA SNIP level validations and compliance reporting and other plan-specific rules can be easily configured in a self-service business rules engine.

5. API-based digital claims submission

   Replaces 837X12 submissions with FHIR API-based digital claims submission, reducing claims settlement cycle time from 5 days to 10 seconds. The Healthcare APIs empower the providers and app developers to build FHIR API-based digital services.

6. Analytics dashboard

   Reporting capabilities include operational and financial reports, business intelligence (BI), and extraction of payment integrity performance, uncovering insights like the number of claims paid inaccurately, percentage of claims dollars paid improperly, and more.

7. Cloud infrastructure

   Built with a loosely coupled microservices-based cloud architecture that enhances scalability and flexibility. Component-based reusable workflows, provide a retail-like experience for customers. The cloud healthcare infrastructure solution accelerator speeds up projects by building a cloud-based infrastructure with healthcare security and compliance best practices.

8. Healthcare data protection toolkit

   Cloud healthcare ‘datathon launcher’ is provided as a toolkit that has the capability to host incidents and events in a  secure computing environment. The toolkit helps to deploy, monitor, and audit projects, ensuring security and compliance with HIPAA and SOC2 standards. Enabled by the cloud provider, it helps to collaboratively tackle the data-related challenges.

Conclusion

Real-time claims processing is fundamental to the strategic demand of the healthcare plan’s ability to respond in real-time to point-of-care claim submissions. Leveraging modern and flexible solutions will minimize organizational complexity, enhance visibility into the core adjudication processes, and increase overall business agility. Real-time claims processing will reduce the overall healthcare administrative cost and enhance the claims and settlement experience for providers and members.

References

• Tseng, Phillip, Robert S. Kaplan, Barak D. Richman, Mahek A. Shah, and Kevin A. Schulman. 2018. “Administrative Costs Associated with Physician Billing and Insurance-Related Activities at an Academic Health Care System.” JAMA319 (7): 691–697.
• Sakowski, Julie Ann, James G. Kahn, Richard G. Kronick, Jeffrey M. Newman, and Harold S. Luft 2009. “Peering into the Black Box: Billing and Insurance Activities in a Medical Group.” Health Affairs 28 (Supplement 1): w544–w554.
• Shaw, M. K., Scott A. Davis, Alan B. Fleischer, Jr, Steven R. Feldman. 2014. “The Duration of Office Visits in the United States, 1993 to 2010.” The American Journal of Managed Care 20 (10): 820.
• Wikler, Elizabeth, Peter Bausch, and David M. Cutler. 2012. “Paper Cuts: Reducing Health Care Administrative Costs.” Center for American Progress.
• Papanicolas, Irene, Liana R Woskie, and Ashish K. Jha. 2018. “Health Care Spending in the United States and Other High-Income Countries.” JAMA 319 (10): 1024–1039.
• Morse, Susan. 2017. “Claims Processing Is in Dire Need of Improvement, but New Approaches Are Helping.” Healthcare Finance.