These were major themes in a discussion at Becker’s Payer Issues Roundtable, led by Sesha Mudunuri, COO of Imagenet. He also discussed the need for redundancy and business continuity plans, the importance of provider data management, and challenges of maintaining up-to-date provider data.
Key takeaways were:
1. Claims adjudication is a critical aspect of health plan operations and requires efficient processes and accurate data. According to Mr. Mudunuri, the bar for program audits is getting higher. “If the quality of adjudication, whether auto or manual, results in an appeal, rework is expensive, frustrating to the providers and negatively affects their reputation,” he said. Better, standardized and more compliant processes are required. “You can’t talk about claims without talking about data.”
2. Technology plays a significant role in claims adjudication, but must be complemented by the expertise and engagement of employees and partners. “It’s not just the technology, but the people that we really need to engage,” Mr. Mudunuri said. “A lot of the claim shops have their best resources focused on upcoming changes. I see a need for creative partnerships to make sure that ongoing business can be handled while the key resources and SMEs focus on the future.”
3. Provider data management is a key challenge in claims adjudication and impacts the efficiency of the process. “Provider data is the underlying key issue that drives everything,” Mr. Mudunuri said. “Keeping on top of provider data is a continuous process because it’s changing as we speak. It’s often a common thread that causes a lot of the issues and abrasion, and that’s where we work with automation to reconcile data cleanup along with manual outreach to validate provider information.”
4. Business continuity planning and redundancy are crucial in mitigating the impact of disruptions, such as cyberattacks or vendor issues. The Change Healthcare incident highlighted the need for redundancy and business continuity plans. “Having a backup plan and understanding what your vendors are doing is important,” Mr. Mudunuri pointed out.
Dealing with the volume and costs of claims adjudication is a major issue for providers. By using technology such as robotic process automation (RPA), standardizing processes and engaging with the right partners, health systems can increase the efficiency of claims adjudication and decrease the costs.
