In traditional claim processing, the lack of interoperability between health plan and provider systems often leads to challenges and inefficiencies, like manual data exchange and a lack of transparency. This results in claim denials that drive unnecessary administrative work and costs as well as abrasion for members and providers. But this is avoidable.
With real-time, automated exchange of eligibility, claim and payment data, health plans can give providers the information they need, when they need it – before a claim is submitted. This enables providers to identify and correct errors upfront, helping reduce denials and the associated administrative rework and costs required to fix them.
Continue reading to learn how creating real-time connections in the provider workflow can help enable more accurate claim submission, prevent denials and create a more efficient healthcare payment system.
Shifting editing into the provider workflow
Without visibility into health plan-specific requirements and policies at the point of coding and billing, providers often don’t have all the information they need to submit accurate claims. This often leads to inaccurate payments, denials and unnecessary rework for both health plans and providers.
Optum is integrating our claim editor to provider practice management systems to give providers real-time insight into health plan-specific editing rules prior to submission. We evaluate provider billing entries against editing rule sets and alert providers to potential errors in near real time, allowing them to take corrective action before submitting claims.
Shifting edits into existing provider workflows helps providers submit claims accurately the first time, reducing preventable denials and administrative waste while minimizing provider abrasion.
Coordinating benefits pre-submission
Today, millions of patients have coverage from multiple plans, but providers lack a full, point-in-time view of patient coverage. This results in providers inadvertently submitting claims to the wrong plan, driving billions of dollars in overpayments and administrative waste due to minimally effective recovery and reclamation processes.1, 2
Optum is giving providers real-time access to our extensive set of eligibility data to help identify and validate primary coverage pre-claim submission. This enables providers to correct COB errors earlier and submit claims to the right plan the first time, avoiding denials and improper payments.
By creating real-time connections with provider systems, health plans can give providers more transparency into up-to-date health plan information. This will help create a more streamlined and efficient healthcare payment system, reducing waste, lowering costs and improving the provider and patient experience.
To read more about the future of payment integrity, explore our best practices and resources.
About Optum
Optum is a leading information and technology-enabled health services business dedicated to helping health plans achieve payment accuracy across the claim lifecycle. We’re helping our clients pay claims accurately and on time, the first time, and prevent denials to drive a more affordable healthcare system for everyone.
About Laika Kayani
Recently named one of Becker’s 100 Women in Health IT to Know in 2025, Laika leads payment integrity product management at Optum, focusing on technology-enabled solutions that help reduce fraud, waste, abuse and error and improve payment accuracy across the claim lifecycle.
1 2024 Optum Revenue Cycle Denials Index.
2 2024 internal Optum data
