Real-time claim adjudication gets X-12 shot

May 25, 2007

While more and more health plans are offering real-time processing of individual claims, this activity is occurring mainly on plan or clearinghouse websites. Most practices are reluctant to participate because they don't want to have to enter claims data on a web site, and then re-enter it into their practice management systems. They could get around this obstacle by generating the claims in their practice management systems. But PM systems are designed to transmit batched claims to clearinghouses, not individual claims to payers or clearinghouses.

While more and more health plans are offering real-time processing of individual claims, this activity is occurring mainly on plan or clearinghouse websites. Most practices are reluctant to participate because they don't want to have to enter claims data on a website, and then re-enter it into their practice management systems. They could get around this obstacle by generating the claims in their practice management systems. But PM systems are designed to transmit batched claims to clearinghouses, not individual claims to payers or clearinghouses.

There are a number of reasons why software vendors haven't yet reprogrammed their billing products to take advantage of real-time claims adjudication (RTCA), as it's known. The most important one is that their customers aren't yet demanding it, because not enough payers are offering it. But even as that changes, there are problems with the "standard" HIPAA claims transaction, which isn't really standard. Most plans will accept only claims that have been tweaked to fit their own information systems—hence, the continuing need for clearinghouses to edit claims from different PM systems so that they can be accepted by different payers.

The Accredited Standards Committee (ASC)-X12, the body that devised the HIPAA transaction set, is trying to change that. Daniel Kazzaz, chairman of ASC-X12, says that RTCA originating in PM systems can only become a reality when there's truly a standard HIPAA claims transaction. ASC-X12 held a conference on the topic in February and will soon launch a project to reduce claim variability, as well as to set new standards for security and communication protocols.

By June of 2008, Kazzaz predicts, some payers should be able to support "real-time interactive communications." He expects "large portions of the commercial market" will be doing this within five years. Stay tuned.

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