Claims Management Software Smoothes Workflow, Saves Money
While automated claims processing systems potentially cost insurers millions of dollars, vendors in the field promise a swift payback through reduced personnel requirements in claims-processing centers, along with fewer errors, less paperwork, speedier workflow processes, and less time spent trying to mollify exasperated beneficiaries.
Some of the key players in claims-processing technology include the following:
IBM, Armonk, N.Y., entered the field in June after inking an agreement with deNovis Inc., a software firm in Lexington, Mass., to run its claims-handling program on IBMs e-business platform.
Its first and, so far, only customer for the IBM-deNovis system is Empire BlueCross BlueShield in New York (currently seeking to reincarnate itself as a public company under the name WellChoice). IBM is also deeply into talks with other health care carriers about using its system, says company spokesman Michael Shore.
Shore declined to cite specific costs. He says his company estimates the IBM-deNovis system potentially could save the health care industry $50 billion to $100 billion a year if it comes into widespread use.
The software is designed to achieve a first-pass ratio well over 90%, says Shore. That ratio refers to the percentage of claims that make it through the system on the first try, without the need for human intervention.
DeNovis software is able to read policy statements and rules and apply them to payment requests automatically, Shore says.
The system is best run on IBM mainframes but could also work under a client-server system, he adds.
A key feature of the IBM-de Novis system is that it simplifies health care administration to the point where the insurer can offer customized policies if it wishes.
“So if you are married with two kids, they could customize your policies for each family members different health care needs,” says Shore. “For instance, you can exclude dental care for a baby, or an employer could customize its policies to give added emphasis to wellness programs.”
Empires system will take about a year to implement, Shore estimates.
FileNET Corporation, Costa Mesa, Calif., which provides business-process automation for a variety of industries, offers a health-insurance platform that it says delivers increased efficiency and improved process management.
John Sarich, FileNETs insurance industry marketing manager, says its Acenza system can be used to process health care, disability and long-term care claims.
The company outsources much of its system to outside vendors, such as optical character recognition technology firms, that can use its software as part of a system built to an insurance companys specifications, Sarich explains.
Claims are a complex process involving the application of numerous company rules for qualification and payment, he notes, and a single claim can involve several providers whose bills arrive piecemeal.