How to Increase Auto-Adjudication Rates in Medical Claims

by | Feb 13, 2023 | Healthcare

Businessperson uses auto adjudication to approve their claim.

Automation feels like the golden ticket to success – you input your claims, and it all magically runs smoothly. While auto-adjudication in healthcare has the potential to be your golden ticket to streamlined claims processing, it does require a small investment. Auto-adjudication relies on data quality and completeness. When you provide the system with the data it needs to run, your claims processing rate will significantly increase.

Learn how to boost your auto-adjudication rates through quality and comprehensive data to maximize your return.

Key Takeaways:
  • Auto-adjudication automatically processes and approves claims using a high-quality database.
  • To improve your auto-adjudication rate, regularly clean and update your database to ensure it’s accurate.
  • Unifying your data connects all parties involved in claims processing.

Why Auto-Adjudication of Claims Is Essential in Healthcare

As more Americans receive access to healthcare, the rate you receive claims will increase. Is your company equipped to handle the increase?

Claims processing is a long, tedious process delayed by outdated manual practices. Healthcare companies also struggle to upgrade and adopt new systems because of the compliance and privacy issues associated with healthcare data.

Today, healthcare organizations struggle with labor shortages and “quiet quitting.” Lack of labor can cause a considerable bottleneck in claims processing if you rely entirely on manual processes.

Manual claims have their place, especially for claims that require special steps or manual reviewing. However, most claims follow a set order, which you can perform much faster using automation.

Auto-adjudication streamlines claims processing while eliminating avoidable errors. This enables companies to speed up claims processing with an approved healthcare system without risking data quality or security. Additionally, a streamlined system results in lower overhead costs, including costly mistakes.

Ultimately, everyone in the payment cycle receives compensation on time as you can quickly process claims, speeding up the adjudication process.


Video: The State of Claims 2022

5 Tips to Improve Your Auto-Adjudication Rates

Once you adopt auto-adjudication, you need to create measures to ensure it runs smoothly – which means fewer claims on your manual to-do list.

Follow these tips for a seamless claims auto-adjudication process that can keep up with your increasing claims rates.

Tip 1: Protect Your Data Quality

Auto-adjudication quickly approves or denies claims, benefiting insurance agents, healthcare providers, and patients. However, this process only works if the claims and the data are correct.

If the system or claim has data errors the system didn’t catch, the automated system will process the claims wrongly, leading to denials and possibly requiring manual review. Mistakes come in from human errors, working with too many data sources, or data ages (which lead to outdated information). Errors can also occur when data is missing.

Set up automated processes in your data management system for storing and preserving data so it’s accurate, including correct spellings, recent addresses, and real-time healthcare updates.

Running a data audit and cleaning is another crucial strategy to preserve data quality. A data audit searches for duplicate information or inconsistencies that may prevent the auto-adjudication system from running smoothly. A data audit also identifies missing information, like missing names on an insurance claim, so you can fix it before running claims through the system, avoiding a denial.


Parts of data quality
Image Source: BMC

Tip 2: Unify Your Data

You might have high-quality data, but if it’s just a raindrop compared to the ocean of available information, that quality data won’t help much. That’s why you also need updated and comprehensive data for successful auto-adjudication.

The more data your adjudication system can access, the more accurate your claims will be. Additionally, you’ll be able to process more claims automatically as you will have the data to run them.

Gaine helps insurance and healthcare providers connect their systems in a cloud-based system. That way, the patient’s insurance and healthcare providers can access the same data. They can also add updated information to a unified database for others involved in the patient’s care and billing. 

If the system is connected to a patient portal, the patient can also fill out online forms and update their information to keep their records correct and complete.


Unified healthcare data
Image Source: COVIDX

Tip 3: Reduce Manual Claims Review

When errors occur, claims go through manual review. Manually reviewing claims causes those delays you were hoping to avoid through auto-adjudication.

If you eliminate most manual reviews, you could boost your auto-adjudication rates by 20-40%.

These errors go back to poor data quality, duplicate data, or mismatched information. Ensuring everyone in the claims process is working with the same information and investing in accurate data entry reduce the number of claims that go through manual review.

Using a quality data management system will reduce manual claims review and other manual tasks eating away at your time. Gaine’s system is an all-in-one platform that does all the manual work for you so you can focus on core business tasks.

Tip 4: Increase Patient Engagement

Patients are the most knowledgeable source of data in the claims process. If you continue engaging patients throughout their care and billing, they’ll consistently provide the information to keep claims running quickly and smoothly.

Patient engagement connects with patients regularly so you’ll receive real-time updates from wearable devices, patient portals, and third-party care. This data informs providers of what care the patient received and what services they are filing claims for to ensure the claim’s accuracy.

Tip 5: Provide Educational Resources

While auto-adjudication can streamline claims filing, it has a learning curve for providers who have been using manual practices for years.

Healthcare providers need updated training and resources to learn the systems. Those in the claims process are more likely to use auto-adjudication if they understand it than do it themselves.

Additionally, the training will teach your teams how to keep data clean and usable so the system continues to run smoothly. This ensures you receive the maximum return from the investment in auto-adjudication.

Even patients benefit from auto-adjudication resources. They can help with data quality and provide comprehensive information online for the system. That way, they’ll receive their invoices faster, and their providers will receive payments on time.


Where Can Your Process Improve?

Are you ready to meet the challenges of 2023?

Auto-adjudication ensures you stay on top of increasing claims, even amid talent shortages. Gaine provides all the support you need from start to finish to ensure you have accurate and real-time data. Through the system, you’ll always have a single source of truth to boost your auto-adjudication rate with minimal effort.

Learn more about the secure data management platform and how to incorporate it into your claims processing system.


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