Streamlining Claims Data Processing for Health Plans

The Challenges of Claims Data Processing

Claims data processing is a core function for all payers as it is a fundamental part of running a successful health plan. However, many organizations struggle with various, if not all, aspects of maintaining a well-operating claims process. These inefficiencies impact virtually every part of the health plan business and can have dramatic implications to the member, provider, operations, finance, population health management, and regulatory reporting. As these inefficiencies surface so do the increased, unnecessary costs minimizing profitability and increasing administrative overhead.

Many organizations often operate with multiple claims systems, a complicated end-to-end workflow, and siloed SME knowledge, which contribute to these inefficiencies. Couple that with the sheer volume of claims that need to be processed and the overall debt burden to the organization can continuously pile up over time − making the remediation process that much more complicated. Staying ahead of claims processing not only allows the staff to have manageable day-to-day workloads, but also improves the member and provider experience. It also allows health plans to stay on top of key analytics, patient care, and regulatory compliance.

The Importance of a Documented Business Process

A fundamental aspect as a starting point for organizations is to ensure the complete business process is documented and fully understood by all the various business units that contribute to claims operations. The process usually includes functions around EDI, trading partners, claims systems, claims inquiry, member/provider portals, finance/actuarial, utilization management, and pharmacy benefit management, amongst others. Without this foundational component, claims business processes are likely not going to make the necessary progress to improve throughput, auto adjudication, or payment. Given the inherent lag of claims processing, organizations are usually playing catch up rather than proactively getting ahead of potential issues or unforeseen spikes in submitted claims. Add to that the desire for health plan expansion and organizations face the potential for not being able drive into new markets or contract out with new provider organizations.

Even with this foundational piece in place, business process improvement is a daunting endeavor that usually requires the right set of reporting, analysis, system improvements, and consistent monitoring. Many organizations do not necessarily have the resources, budget, or tools to enable this type of a comprehensive roadmap further extending the journey to a sustainable claims operation.

Introducing the Health Data Management Platform (HDMP)

With the introduction of a Health Data Management Platform (HDMP), this holistic approach can be achieved in a manageable timeframe with visible, measurable improvements. We at Gaine have spent considerable time over the past years working with health plans to outline an approach that leverages our Coperor HDMP to achieve all the necessary goals to improve claims processing, payment, validation, and reporting, while helping reduce errors and lower administrative costs.

We start by ensuring that both the client and Gaine fully understand the foundational business workflow. This understanding allows for the planning and phased implementation of a data management roadmap, which incrementally improves processes over time and leads to a sustainable, ongoing system. By mapping out all the various end points where claims data is being managed, those systems can be consumed into the Coperor platform and organized appropriately within the HDX data model while accounting for any specific business nuances that need to be managed from a data perspective.

Creating Golden Profiles for Data Validation

Creating the necessary golden profiles for members, providers, organizations, facilities, and locations, while also relating those profiles to the claims transactional data, allows Coperor to begin the journey for data validation, auditing, deduplication, trending, reporting, and analytics.

The Role of Regular Data Audits

Implementing regular data audits is crucial for identifying and addressing data quality issues in real-time. These audits bring to light any discrepancies or errors, allowing business units to promptly resolve them, thereby maintaining the integrity and reliability of data for decision-making processes. This results in enhanced processing efficiency and more effective auto adjudication, allowing members to receive timely updates on their claims and faster Explanation of Benefits (EOB) statements.

Improving Provider Payment Cycles

Providers also see improvement in payment cycles which is a dramatic burden in the current healthcare landscape, one that they cannot afford to have to keep their business running. It also reduces provider abrasion and the need for things like having to resubmit claims which drive up their administrative costs along with the health plans.

Achieving a Longitudinal View of Data

Coperor's focus on data management, utilizing industry-proven technology tailored for healthcare and life sciences − with a very mature data model − allows organizations to quickly integrate their data into the platform. This enables them to gain a longitudinal view of how data aligns over time, providing a comprehensive view of patient interactions and health trends. Additionally, it allows organizations to concentrate on integration patterns that feed back into their systems and analytics, ensuring the data is delivered with the necessary precision, accuracy, and timing.

In Conclusion

In conclusion, the journey to a sustainable and efficient claims data processing system is achievable with the right tools and approach. By leveraging the Coperor Health Data Management Platform, you can streamline your operations, reduce costs, and improve outcomes for members and providers alike. More information about how Gaine helps with claims processing is here. Or Contact us today to learn more about how we can help transform your claims processing and drive your health plan's success.