Why combining human expertise and technology is imperative in modernizing claims management

Across every industry, rapid digital transformation has been underway for decades, ushering in greater efficiencies. Within the healthcare industry, the story is a bit different. On the clinical side, advancements are happening daily. In contrast, the financial side of healthcare—billing, claims management, payments and communications—largely relies on legacy, paper-based, error-prone processes. The result is unnecessary friction and outsized administrative burden that complicates the healthcare financial experience for everyone. 

Claims management is a complex part of the financial side of healthcare with many manual processes and a lack of interoperability between adjudication and payments systems. A 2022 CAQH Index found the healthcare system spent $60 billion on administrative transactions, with potential savings of nearly $25 billion achievable through full automation.

While the financial side of healthcare is imperfect today, progress is possible, and there are signs of progress already underway. What if we could modernize and streamline claims management in a way that truly enables care to flow?

Simplifying and streamlining current processes

According to PwC's Health Research Institute, healthcare costs in individual and group markets are projected to increase by 8% in 2025. This expected increase underscores the necessity for accurate claims and reviews.

But the lifecycle of a claim is complicated, and claims management is more than just a math equation. Claims require meticulous review for accuracy and completion, looking at details such as treatment codes and documentation, and certain claims are more prone to errors, largely due to their clinical complexity. It is also cumbersome to keep claims editing workflows up to date with the latest coding updates and regulatory requirements.

Addressing these challenges requires a combination of technology, process improvements, effective communication and the oversight of trained experts. 

A modernized claims review workflow integrates human expertise with advanced technology to meet strict turnaround times and navigate the complexity of claim management. This includes initial evaluation of the claim, efficient adjudication, intelligent selection of claims for further review, swift retrieval of necessary documents, thorough claim examination, application of appropriate pricing structures, and comprehensive support and service.

Ensuring claims are paid correctly the first time is a hallmark of an effective claims review program. Fast turnaround time is crucial to meeting prompt payment requirements. Automation enables claims to be intelligently routed to the right expert claims reviewer with actionable intelligence at their fingertips. Utilizing technology to correctly process claims from the outset can reduce administrative costs and keep providers from getting tied up in billing and coding nuances, allowing more time and focus on patient care.

AI and automation technologies empower health plans with the ability to efficiently process, standardize and route large volumes of data across various systems, reducing manual, error-prone workflows. Machine learning models can identify patterns, detect anomalies and improve over time as they encounter more data, while natural language processing can interpret unstructured data such as clinical notes or complex descriptions. Alongside automation to handle repetitive tasks within the workflow, including data entry and verification, these technologies drive consistency and accuracy in claims management.

The right combination of technology and human expertise

Modernizing claims management with a focus on accuracy and transparency requires more than just advanced technology; it requires inserting the right expert oversight into the process. This is essential as the complexity of claims data often needs human interpretation, particularly in cases like itemized bill review, clinical chart review, DRG evaluation, dialysis review and pre- to post-pay claims review.

Technology should work with humans to ensure the most equitable decisions are made. Supported by technology, claims review experts make informed decisions faster so claims can flow more seamlessly. 

Human touch is equally critical for communication and education regarding claims, especially denials. Clear communication is essential to reduce misunderstandings and disagreements. When payers clearly communicate and provide transparency for the reasons behind denials, it can prevent future coding and billing errors, reducing potential conflicts and fostering a more collaborative environment.

This delicate balance makes it possible to deliver accurate results and a better experience for healthcare providers. An external partner with the right blend of AI and human expertise can optimize the claims management process by targeting accurate pricing the first time rather than focusing on making back-end corrections.

When claims flow, care flows

When we get the pricing recommendations right the first time and provide a high-quality review, it builds trust for everyone involved. It fosters confidence in the healthcare system and allows care to flow.