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Getting Real About Claims Processing

Jul 24, 2013

NewVantage Partners Healthcare Practice Leader Carl Ascenzo is interviewed by Health Data Management for the article Getting Real, which looks at real-time claims adjudication and how its absence is hurting the industry as snarled operations and new reimbursement models demand a solution. Read on to learn why Carl, former CIO of Blue Cross Blue Shield of Massachusetts, thinks the real growth area will be auto-adjudication.

Click here to read the article in full. See excerpt below:

Passport can return its price estimation within seconds, crunching its own numbers against the eligibility information returned by the payer in real-time, Padgett says.

For providers, knowing the patient obligation at the time of service would help, adds Carl Ascenzo, partner at Boston-based NewVantage, an I.T. consulting firm.

“Knowing the patient liability at the time of service prevents them from having to chase the patient later,” he says. But payers themselves face many challenges in adjudicating claims, adds Ascenzo, the former CIO at BlueCross BlueShield Massachusetts.

“There are many considerations the payer can’t resolve, such as coordination of benefits if the patient’s primary insurance is through another company, or other claims from the patient that have come through and pended, that could change the amount of the patient deductible.”

Ascenzo doesn’t envision much expansion of real-time claim adjudication, but does see growth in real-time adjudication’s cousin, auto-adjudication. In auto-adjudication, once a claim arrives at a payer’s doorstep, it can pass through payer processing systems and wind up being settled—without human intervention.

Auto-adjudication doesn’t happen instantly, as claims run through various edits in batches, but eliminating human review is far more cost-effective and the process can expedite payments, experts say. Auto-adjudication doesn’t depend on a provider keying in and submitting a claim in real-time, as a payer could auto-adjudicate claims being sent in batches overnight from clearinghouses or directly from providers.

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