Reinventing Claims Payment For A Value-Based World

By Amy Larsson, RN, BSN, MBA, Vice President, Clinical Claims Management, Change Healthcare

Payers need to choose between automated payment and accurate automated payment

The U.S. healthcare industry’s claims-payment system is frustrating to providers, payers, and patients alike. Inefficiency and a systemwide tendency for error wastes precious resources, worsens miscommunication and mistrust among all stakeholders, and inhibits the ability to transition to value-based approaches that achieve better outcomes. We need to rethink our industry’s disjointed and siloed approach in order to solve a very integrated problem.

Despite billions invested in achieving efficient claims payment, more than 7% of claims are not paid correctly the first time, the second time, and sometimes even the third time¹. The remediation process costs health plans more than $43 billion annually². Indeed, an entire sector of the industry has evolved to examine claims retrospectively, identify inaccurate payments, and reconcile over- and under- payments. This broad “pay and chase” approach increases administrative costs for the entire industry.

Not only does this waste time and money, but it also impedes providers’ ability to manage their revenue cycle effectively, erodes their confidence in payers, and creates a barrier to closer strategic alignment. Consumers are also impacted. Like providers, they have a reasonable expectation that claims should be paid accurately and quickly the first time, and that the system should be focused on delivering good healthcare–and not rectifying payments.