How automated information management can streamline insurance claims

Insurance plans and payers manage tremendous amounts of data related to their member accounts. This data often exists in various forms: Printed letters, emails, faxes, phone recordings-you get the picture.

According to CAQH, hundreds of millions¹ of phone calls are handled by health plans across the U.S. each year, so it’s really no surprise to hear dental office managers relaying their frustrations with XYZ payer. These complaints vary, but usually have something to do with payers having “no record” of receiving a submitted document-especially true if the claim hasn’t been submitted electronically and there’s no tracking available. 

CAQH research states “access to IT systems and software capable of consistently executing and updating fully electronic transactions is critical,”¹â€¯and payers are increasingly turning to technology for the task. Until recently, data collation had been a combination of manual processes-receiving documents via mail or fax, scanning these documents into electronic form and importing them to the appropriate member record. With data coming in from multiple sources to payers, there’s a constant need for process improvement. 

Solutions that automate claims management and adjudication are a welcome sight. Payers now have access to solutions that can collate and manage millions of member calls and untold amounts of information from disparate systems, faxes and documents-into a single record. 

This collation of member information translates into the ability to better manage information, creating quality and efficiency controls. Payers can turn data caches into information repositories, making individual patient data accessible, dissectible and searchable by record and per interaction. According to the needs of the organization, member information can be easily accessed and used by teams to enhance client service efforts and provide any required reporting.

How does record consolidation work? 

Collation and communication management technologies capture, centralize and allow for searching and querying data pieces by fields, such as “patient” and “document type,” or any custom field needed to index, report and capture business intelligence.

Voice 

Audio content, such as phone calls, voicemails and any face-to-face interaction through PCs, mobile devices and even desktop-based microphones can be captured with ease. With voice capture, any two-party communication is recordable via phone, secure messaging and pre-authorization conversations between payers and providers can be rendered. Other types of communication capture can include conversations regarding patient acknowledgement of financial responsibility; faxes to/from referring providers; and supporting documentation for claims. 

Fax 

Fax data capture can be integrated with existing solutions eliminating the need to print, scan and manually review these documents. Images can be captured, indexed, stored or routed through collation technology to any outside party or receiving system. Through the integration of the capture technology with health information system platforms, payers can communicate with providers to easily send and receive content, images and audio links between systems, including direct file transfer (DFT) and content links through either a feed or HL7. Audio files can be linked directly to a member’s record, and indexed and stored for playback, download, routing and quality scoring. 

Measurable results and the impacts 

As data comes from multiple sources generated through the use of an insurance plan, the payers that service these plans constantly seek solutions that automate claims management and adjudication with as few resources as possible. Collection solutions can be implemented by a single department or as an enterprise solution, to create a chronological, auditable trail that can be dissected granularly, with information including the provider generating a claim, the member covered by the plan, the employer offering the plan and other relevant indexing criteria.

These solutions lead to improved claim tracking and adjudication; reduction in lost time; and possible revenue improvements because of the availability of immediately accessible data. A reduction of massive amounts of paper documentation and the ability to convert data from thousands of calls weekly into useful, actionable information also has a powerful impact. 

Data collation enables opportunities for growth and can even be used as a driver for conversations with patients. Smart data management can help payers monetize and improve operations while enhancing customer service. Finally, collating patient-related data means organizations can improve relationships with members and care providers. 

The bottom line is that automatic data capture gives organizations the ability to capture and analyze massive amounts data, a process that has previously been next to impossible with traditional, manual and often paper-based data collation procedures.

¹ 2016 CAQH Index Report