Integrating claims systems with medical management, bill review, UR, and other applications is the holy grail; yet few payers are really, truly, actually “connected”. There’s far too much cutting-and-pasting, systems store pictures of documents instead of capturing key fields on those documents in electronic format, too many yellow stickies on the display stand, lots of toggling back-and-forth between systems, double-, triple, or quadruple-entry of claimant data – you know the drill.
Many reading this likely believe their systems are “integrated”. And many of these many would be mistaken. A survey we conducted in 2010 found four-fifths of claims handlers did not believe their systems were “fully integrated’; almost as many executives believed they were.
There are any number of reasons to integrate these systems, Acrometis has picked six.
They include reduction in network leakage and overpayment of medical bills; higher network penetration; better vendor management; improved direction of care; more effective and accurate state reporting; and enhanced overall efficiency.
Hard to argue with any of these, and even harder to understand why it’s 2012 and adjusters are still stuck toggling between systems, double-entering data, and cutting and pasting from a medical management system into claims. Not only does the lack of integration waste time, it also increases error rates, frustrates adjusters and other claim handlers, and increases medical expense.
It also makes it difficult for payers to comply with unique policyholder or customer demands, limiting the payer’s ability to compete for and win new business.
We are in an “interesting” time; the work comp market is hardening, medical costs increasing, rules and regs changing in several key jurisdictions, and customer demands increasing in number and complexity. Yet insurers and TPAs are still under-staffed, all lack adequate IT resources, there’s precious little time for training, and new competitors are entering the comp market, seeing opportunity to gain from the upswing in pricing.
What does this mean for you?
Successful payers are those that adapt, maximize their resources, and eliminate duplicate work and errors.
Jul
11
Joe,
This is one my biggest frustrations and you are absolutely correct, that this is the Holy Grail.
How much slippage is out there is the great question. I can think of many times, when I know a nurse has negotiated a discounted rate at less then the PPO/fee schedule rate. The bill comes in for review and the charge is paid based on the contracted rate and the negotiated savings is lost.
This is just one of many examples I could supply where this type of action occurs.
If this was ever addressed satisfactorily the savings for the industry would be significant.
You are spot on, Joe. Clients who use software to provide claims adjusters, UR and case management nurses, physicians and bill review specialists and others with simultaneous access to the claims file experience significant productivity gains … and do a better job of treating injured workers.
Your review of the Acrometis system is laudatory because it highlights the need for greater integration in the claims processing system.
Having said that, I did not get more than platitudes from the Acrometis monograph. There is no doubt that “integration” is the way to go but where in the continuum Acromoetis’ “platform” comes in to play seems to me to be far too late to accomplish the “cost savings” they predict or expect.
Back in the day, Physician offices were (IT-wise) about 5 years behind work comp carriers (and the rest of the business world). However, most of us (physician offices) are now on EMRs and are working to develop systems to share clinical information amoung offices (electronically). If small physicians offices have the will and the means to invest in 21st Century technoloy, why not wc carriers? Very frustrating to have to print and fax or mail our progress notes when we ( physicain offices) have the ability to transmit electronically.
The “monograph” was not intended to be a white paper on a point solution but rather a discussion on the merits of integration and thinking about integration. However, we can point to 10 years of operation of an integrated solution with actual results achieved and measure by third party evaluators. The integration we develop is directed at driving costs out of the enterprise as soon as they can. For instance a operation should not invoke it’s entire spend to determine at the end of the process to not pay a billed service. An example of bad integration is to have all bills flow through the workshop then export to the bill review vendor and have the bill review vendor determine that the bill is a duplicate,not related to the claim or even not related to any covered worker for that payor. That determination should be made very early in a workflow. We work with clients to determine the optimal place for each decision, based on the possible outcome of the decision then automate that process. We also work with clients to develop managed care solutions that work to prevent services rather than deny payment on services that were delivered. Prevention of unrelated service is the optimal savings point from a timing perspective. Denying unrelated and early in a process is the next best from a timing perspective. If the service is related and necessary, then getting the best price is the next opportunity. Doing all of that with as much of that with efficient, cloud based service automation is the pinnacle we work toward in our solutions.
Integration is key to reducing operating costs. So is the timing of filters and business rule. But what is really intriguing is gaining access to an integrated data repository for across-the-board visibility into vendor performance, treatment strategies and how that performance ties to the claims and medical outcomes.