Real-Time Claims Adjudication Enables Faster Payment to Providers

As mentioned in previous issues of Humana’s YourPractice, Humana is the only health benefits company in the nation offering real-time claims adjudication. Throughout 2006, Humana continues to make this solution available to providers across the country. This integrated process will save health care providers time by simplifying administrative tasks and helping providers quickly receive the correct payments for patient services.

While the advent of health care savings accounts (HSAs), health reimbursement arrangements (HRAs) and flexible spending accounts (FSAs) has been advantageous for patients, it also has caused new headaches for many health care providers and their billing staffs. In addition, high-deductible health plans (HDHPs) continue to grow in popularity with employers. Providers often face difficulty knowing how much money to collect from patients at the time of service. Providers need to know whether the patient has met his or her deductible in order to know the portion of a claim for which the patient is responsible.

Currently, providers send claims to Humana either electronically or by mail. The claims process has to be “adjudicated,” which takes into account the specific member’s benefits and health plan discounts. Once the claim is paid, providers must then bill the member for the balance.

Humana’s real-time claims adjudication solutions allow providers to verify the total charges for a claim — including the amount covered by Humana, the total amount the patient owes and any remaining deductible amount — within seconds, and before the patient ever leaves the office. The result is improved cash flow for health care providers and less staff time dedicated to billing patients. It also reduces potential accounts receivable issues, such as reconciling estimates of the patient’s cost with the actual amount due, issuing refunds, billing patients for any unpaid amount and waiting for or having to collect the patient’s portion.

“This new capability is a much more realistic and efficient approach than any other options that are available to physicians today,” said Bruce Perkins, Humana’s senior vice president for national contracting. “It replaces other alternatives that involve time-consuming administrative office hassles, such as duplicative, manual keying of claims information, with one-time entry, followed by an instant swipe of a debit card.”

Those other alternatives require patient information to be manually keyed into a computer or card terminal, much like manually keying in the bar code of a grocery item. That method is time-consuming and can lead to errors in data entry.

“Until now, the problem doctors had with using real-time claims solutions has been the hassle factor,” said Bruce J. Goodman, Humana’s senior vice president and chief information officer. “No one wants to enter the same information twice and into two different systems.”

For most of its members, Humana’s real-time claims adjudication offers a simpler administrative approach. Once a claim is entered using the provider’s practice management system, the claim is submitted electronically to Humana’s clearinghouse. The clearinghouse immediately sends the claim to Humana for adjudication. Humana’s system returns the adjudicated claim through the clearinghouse to the provider’s office. Within 30 seconds, the provider’s office knows exactly what to charge the Humana member. It can be instantly deducted from his/her health care savings account (HSA), health reimbursement arrangement (HRA) and/or flexible spending account (FSA) using the HumanaAccess^sm Visa®. Humana’s portion of the claim is paid in the normal weekly cycle for electronic claims submission.

MacGregor Medical Center in San Antonio, Texas, is already using Humana’s real-time claims adjudication process, and has seen effective results.

“There’s no doubt that we have seen cash flow benefits,” said Terri Foose, chief financial officer of MacGregor Medical Center. “But in addition to that, we have seen improvements in patient satisfaction and in our ability to communicate with them. We are also realizing a savings in the cost of sending statements, rebilling and talking to patients about charges over the telephone. It has made for a much more efficient operation.”

William Jessee, M.D., FACMPE, president and chief executive officer of Medical Group Management Association (MGMA), agrees that Humana’s real-time claims adjudication initiative is a step in the right direction. “It is a start toward a much-needed solution to one of the greatest problems faced by medical group practices — administrative complexity in the payment system. We support national, multipayer solutions to this problem, and we appreciate Humana’s leadership.”

For more information about real-time claims adjudication and its availability in your area, visit www.humana.com. After entering the “Provider Resource Center,” click on “What’s New.” Then, click on the “Real-time claims adjudication” link. Or, send an e-mail to Deployment@Humana.com.

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