Efficiency, accuracy and automation. These are three important goals for any claims operation. The more claims can be adjudicated automatically, the lower the cost, the higher the productivity, accuracy and profitability. Poor provider data quality significantly affects your claims operation - when provider information is outdated or inaccurate, a growing volume of claims fall out of the automated process and require manual intervention or adjustment. As a result, work backs up, errors and rework increase, and penalties can be incurred.

 

A claim that is processed manually costs you about $8 more than one that is processed electronically. Thirty to 40% of the records in a typical legacy provider file have inaccurate or missing data. Incorrect attributes such as service address, NPI, Tax ID and billing information cause a lower auto-adjudication rate. Typically, about 20% of claims fall out, and "provider not found" and "provider mismatch" issues cause 5-10% of that fall out. Since each member typically submits 10 claims per year, that means a payer with 500,000 covered lives will have 50,000 to 100,000 claims fall out each year that could have been prevented - and will spend between $400,000 and $800,000 unnecessarily. Do the math for yourself: every ten thousand claims that fall out unnecessarily today reduce your bottom line by about $80,000.

 

When a claim is processed and paid incorrectly, rework increases. The cost to fix an incorrectly processed and finalized claim exceeds $15 per adjustment. Beyond the manual effort to fix the incorrect claim, you often must contend with related phone calls, and issues related to provider and member dissatisfaction. Avoiding rework related to incorrect provider information saves on operational expense, and provides opportunity to utilize highly trained adjustment staff for other functions.

 

When claims don't adjudicate automatically, the manual process affects timeliness. Claims that are not paid promptly not only cause missed internal goals. They drive increased performance guarantee and late payment interest penalties and fines, which can add significantly to the cost of operations.

 

It doesn't have to be this way. The key to efficient claims operations, a higher level of auto-adjudication and reduced rework is a correct and current provider file and claim record. If only there were an advanced, automated and intelligent way to standardize, cleanse and augment incorrect and outdated provider information, and keep it that way. Imagine the savings in time and being able to deploy your staff to tasks that could make you money.

 

The good news is that there is such a solution. We call it Enclarity. By delivering a rapid and highly accurate way to cleanse, standardize and augment provider files, claim records and keep them that way with our ProviderPoint® solution, we're revolutionizing provider information accuracy and claim efficiency.

 

Our ProviderPoint family has grown to include specialized solutions for improving claims management. ProviderPoint for Claims Cleansing lets healthcare payers automatically validate and correct key issues on claims, and stay alerted that research is needed about the provider (rendering, billing or referring) as each claim is submitted. Another Enclarity solution, ProviderPoint for Claims Indexing, identifies and links unique healthcare providers across claims stored in databases or a data warehouse, regardless of changes to name and business affiliation, TIN, Provider ID, practice or billing information over time.

 

Enclarity can help you dramatically improve the efficiency of your claims operations by assuring that the provider file is standardized and cleansed and missing data is filled in. Enclarity can also improve the selection of the right provider for each claim, and fill in missing information. When a clean, complete claim meets a clean, complete file, the best matching and highest throughput is achieved.

 

For those needing to research individual providers, our Web-based ProviderLookup® solution makes research for claims, adjustments and returned mail a snap. ProviderLookup enables claims teams to rapidly assist members and providers and helps provider operations staffs verify and update records. Enclarity NPI Match® makes the work of National Provider Identifier compliance much easier, minimizing claim rejects, manual intervention and timeliness delays.

 

By working with Enclarity, you can keep your provider information files and claims correct and up-to-date today and tomorrow. You'll see the improvements in higher auto-adjudication rates, decreased manual work, improved claim accuracy, reduced volumes of rework, significantly less returned mail, better use of claims resources, and lower fines and penalties. Powered by Enclarity, your claims operations can finally run the way you always imagined.

 

Next: Provider Data Operations