Real time claims adjudication for real!

February 9, 2007
Ken Terry
Ken Terry

The author is a former senior editor of <i>Medical Economics</i>.

The technology for health plans to process claims online in real time has been available for several years (Medical Economics, "Claims in, approval out&#151;in seconds," July 9, 2001). But until recently, there hasn't been any compelling reason for plans to invest in that when they could hold onto physicians' money instead. Now, however, the advent of health savings accounts and the growth of patient cost-sharing have prompted several plans to take a second look at real-time claims adjudication. The idea is to tell patients what they owe at the point of care, so that their payments can be deducted automatically from their health savings accounts or flexible spending accounts.

The technology for health plans to process claims online in real time has been available for several years (Medical Economics, "Claims in, approval out—in seconds," July 9, 2001). But until recently, there hasn't been any compelling reason for plans to invest in that when they could hold onto physicians' money instead. Now, however, the advent of health savings accounts and the growth of patient cost-sharing have prompted several plans to take a second look at real-time claims adjudication. The idea is to tell patients what they owe at the point of care, so that their payments can be deducted automatically from their health savings accounts or flexible spending accounts.

United HealthGroup—which owns an HSA-qualified bank—recently became the first insurer to roll out real-time claim adjudication nationally. It did so at the same time that it issued "integrated health cards" to all of its members. Besides serving as debit cards for HSAs and FSAs stored in banks, these "smart" little pieces of plastic will give your staff eligibility and benefit information on patients when they swipe them through credit card terminals. And, when the United card is dragged through a USB card reader attached to a computer, it calls up a patient's personal health record at www.myuhc.com, if the patient has given you permission to view it. (While USB card readers aren't common in physician's offices, they cost only $20-$40 online or at a computer store.) The PHR, which is automatically created for all United members, includes data on medical conditions, medication history, past procedures, and lab results.

The integrated card makes real time claims processing simple for the physician office. When a patient comes in and a staffer swipes his or her card, "it automatically populates all the relevant eligibility information," notes United Healthcare spokesman Daryl Richard. "When it comes to the real-time claims adjudication process, there's no need to key in all the information that you would to process a claim. The eligibility information is already in there. All you have to do is put in the relevant CPT code and hit 'submit,' and within 10 seconds or less, you get an approval back on a fully processed claim. It will tell you how much United Healthcare is reimbursing the doctor and how much the patient may owe if he or she has a balance due."

United launched real-time claims adjudication nationwide at the end of 2006. By mid-January, it was processing about 20,000 claims a week in real time. Richard admits that's small compared to United's national volume of 5 million claims a week, but he says the plan hopes to raise the number "exponentially."