The Importance of Modernizing the Healthcare Claims Process for Payers, Providers and Members

Updated on April 19, 2022

By Alexis Blackstead, SVP, Product-Payments, Zelis

Today’s healthcare ecosystem reveals the flaws of longstanding paper-based communications and manual payments systems. Tack on global paper supply chain issues due to COVID-19 and the impact is significantly greater.  While healthcare technology has progressed over time, the most vulnerable and member-facing aspects of healthcare (besides physical appointments) have yet to upgrade to today’s technological standards. Electronic healthcare payments are the industry’s gold standard, which is why it is imperative for companies to embrace new initiatives sooner than later. 

Changing the payment claims processes is not solely for member benefit; payers and providers will also see the rewards of technology payment integration. The payment ecosystem currently uses a well-established paper cycle, and the challenge lies in adopting new methods of processing. 

Current Payment Paper Cycle

  1. Payers send paper Explanation of Benefits to members
  2. Providers send paper bills to members 
  3. Payers send paper checks to providers
  4. Members submit paper checks to providers to cover their remaining medical costs 

Electronic claims payment can help eliminate wait times and processing for payments, ensuring satisfied parties on all sides of the claims equation. 

Additionally, processing manual payment claims has undoubtedly created more work for both providers and payers. The patience expected of members for back-end processing times leads to increased call center requests and substandard customer experiences. Aside from the demand for representatives to assist members and answer their questions, obtaining the information being asked for is no small feat. Pulling payment and health records requires extensive time, especially if healthcare organizations keep physical copies on file. To remedy manually searching for information, digitizing this process can save hours and even days of work per claim, reducing costs and staffing shortages currently prevalent across the industry. 

Platforms are being developed that use the strengths of artificial intelligence (AI), machine learning (ML), robotic processing automation (RPA), and natural language processing (NLP) to help better deliver the right information – pulling the proverbial needle from the haystack every time. Implementing technological components can transform the way information processing functions for data management, and many other areas of healthcare. Leveraging these tools allows companies the unique opportunity to heighten their member experience and reduces a large amount of the preliminary work. Currently, without AI capabilities, companies are drowning in data with no rationalization in place to sort and make sense of it. Integrating AI components into the payments model will advantageously provide companies with the ability to use data that have been gathered and stored. 

Collectively, data from various systems could be extremely beneficial in reaching desired health outcomes, but systems are siloed and incompatible, effectively rendering the data useless. A remedy to this process is the implementation of NLP solutions. NLP is imperative to data management because it not only quickly processes data, but also synthesizes for interpretation. Instead of sifting through 10,000-page documents, NLP directs the user to the source of information and better yet, provides a synopsis. Some companies have already started using components of AI, NLP, ML and RPA, but the key lies in providing user training to maximize the investment through implementation. Once the platform is correctly implemented, ease of use and member experience will improve, and the current confusion associated with manual claims and payments will dissipate. 

Electronic payment claims paired with proper tools and technology are a solution to meet the needs of on-demand access to information and to drive greater efficiencies in claims management. The key to the future success of payers and providers is to proactively implement digital payment systems and data management tools. Virtualizing all these factors will streamline the claims process and lead to a more cohesive and modernized healthcare ecosystem benefiting all payers, providers, and members. 

About Alexis Blackstead 

Alexis Blackstead has more than 20 years of experience in the billing and payments industry overseeing product, development, QA, project management, technical sales support, and marketing.  Currently, she leads product and is responsible for creating, executing and maintaining the Payments Optimization product portfolio and product strategy for Zelis.

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The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.