The Path to Point-of-Service Payment Success: Process Automation and Intelligent Workflow

Greg Burgess, President and Chief Product Officer, spoke at the 2019 AHIP Institute & Expo on “The Path to Point-of-Service Payment Success.” Below is the third in a series that dives deeper into the advancements in technology that will bring us closer to accurate point-of-care payments in healthcare.

Imagine an expectant mother has high blood pressure and goes to see a specialist. After the visit, the provider submits the claim to her insurance plan, and from there it goes through a lengthy administration process. The insurance plan performs complex eligibility and benefits checks, provider contract checks, claims editing and pricing checks, and pushes the claim through several internal and external third-party solutions. Eventually, a reimbursement amount returns, but it moves to a medical records review, and is sent back for another trip through the review process.

This case illustrates the complexities that often occur in the claims payment workflow. There are many time-consuming and redundant steps — sometimes more than 100 — to proper reimbursement. With this system, it’s evident why there is so much uncertainty about how much the expectant mother will have to pay the specialist.

But what if we created a smart and efficient workflow that achieves payment integrity the first time? Think about how much easier this can be for everyone involved — from claims administrators to the healthcare specialist to the expectant mother. By employing process automation and intelligent workflow, we can take a significant step toward eliminating errors, speeding up the claims process, and moving closer to accurate point-of-service pricing.

Work smarter, not harder

From Robotic Process Automation (RPA) that mimics human processes to Artificial Intelligence (AI) for Automation that can make decisions without human intervention, automation is embedded in our daily lives. Consider smartphone technology that offers process automation for routine tasks. Remember when we had to connect our phones to a computer by a cable to back up our photos, documents, and contacts? Now, we can access all our important files from anywhere thanks to automatic cloud backup. Automation allows us to think about more complex tasks, and not be slowed down or disrupted by simple ones. Additionally, it removes human error and makes us more efficient and accurate.

Now, envision this level of automation in the claims process — how many user errors can be eliminated? How much time can be saved? The expectant mother could get quicker and more accurate answers, reducing frustration, complexity, and processing time. Automation and smart workflows are crucial to moving everyone toward real-time, accurate point-of-service payments.

How can we enable it?

Emerging healthcare technology solutions unify disjointed claims payment solutions and enable automation. Implementing automation and intelligent workflow technology takes the human elements (e.g., policies, edits, pricing, adjudication) and creates an ecosystem so well-designed that manual efforts are nominal in the claims process if not eliminated entirely.

To effectively enable automation, health plans must employ technologies that consider:

  • Interoperability of solutions
  • Synchronization of update cycles
  • Scalability

Interoperable solutions seamlessly tie together disjointed components of the payment process so that complex communications can be translated into a common language. This ensures that results are streamlined, and true accuracy is achieved.

With automation and smart workflows, disparate solutions can be modified to have synchronized update cycles. Solutions that are passing information back and forth can share up-to-date data, and health plans can make intelligent decisions based on this data. Synchronization ensures that data is accurate and consistent as it feeds into multiple processes.

With an interoperable, accurate solution in place, a cloud-based environment (see “Cloud-based Data Delivery”) makes it easy for health plans to quickly and efficiently scale for their evolving needs. Automation costs significantly less than manual work, operates around the clock, and is less vulnerable to human error. It also has a substantial impact on a patient’s experience. The expectant mother does not need to wait for answers about her payments and can trust her health plan and provider to deliver upfront and accurate billing.   

Accelerate to point-of-service payment success

Process automation and intelligent workflows can save payers time and money while bringing us closer to point-of-service payments. Financially, the savings from these types of payment integrity processes are abundant. Gartner states that “automation optimizes data, process and workflow efficiency, reliably delivering substantial administrative cost savings.”1

Automating claims-related business transactions and enabling an intelligent workflow, which includes enormous tasks like eligibility and benefit verification, prior authorization, claim submission, claim status inquiry, claim payment, and remittance advice, has the potential to save $9.5 billion industry wide.2 Even if we only automated 20 percent of our workflow, this could equate to nearly $2 billion in savings for payers and providers. These real-time, automated technologies can have a transformative effect on health plans and the providers and patients they support.

We need to stop applying quick fixes to a broken system, and instead look at a workflow management tool that enables an entire ecosystem to support lasting change (see “Integrated Ecosystems). Even though it may be difficult to foresee the impact, this holistic change is necessary to achieve true point-of-service pricing — where one day, patients like the expectant mother can pay the correct amount for the care they receive with full transparency of fees the moment a healthcare professional renders service.

How do we get there?

Despite best efforts to modernize their payment integrity processes, many health plans still do not seamlessly automate and connect their disparate systems or integrate solutions that allow them to scale for evolving needs. In the Hype Cycle for U.S. Healthcare Payers, 2019 Gartner states that Prospective Payment Integrity Solutions market penetration has reached 5% to 20% of its target audience. The report states, “prospective payment integrity solutions enable payers to proactively avoid paying claims improperly, rather than focusing on the pay-and-chase activities that define retrospective payment integrity solutions.”3

Moving our industry toward accurate point-of-service payments cannot happen overnight. The task may be daunting, but we must understand how to set up the industry for success. The steps include:

  • Getting our data in the cloud
  • Creating an integrated ecosystem
  • Incorporating process automation and intelligent workflows

Payers can initiate this approach by creating payment integrity and transformation teams, staffed with representatives from IT, claims processing, and other stakeholders, then choosing a technology provider to help support this transition. Payers can also make payment integrity and point-of-service pricing part of their key performance indicators and long-term goals, creating incentives for departments to support this endeavor.

The payers and technology providers in the healthcare industry share the unique opportunity and responsibility to address these challenges, determine the solution, and move toward it. We have the power to drive the industry forward. With the technology available and a focus on these long-term principles, we can make point-of-service payment success a reality. From the health plans who process the claims, to the providers who accept the payments, and to patients like the expectant mother, this vision will create a better experience for all.

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1 Gartner, "Healthcare Innovation Trends: Bending the Healthcare Cost Curve," Mandi Bishop, Sachin Dev, 7 October 2019

2 CAQH, "10 Takeaways from the Latest CAQH Index Report," July 2018

3 Gartner, "Hype Cycle for U.S. Healthcare Payers, 2019," Bryan Cole, et al, 18 July 2019

About Burgess

Burgess is dedicated to improving healthcare payment operations through technology. We bring technology innovation and real-time data to an overlooked and critical part of the American healthcare system. Our scalable Payment Accountability® platform, Burgess Source®, integrates payer systems to transform payment workflows and provide powerful business intelligence to lift payer performance. The company is located in Alexandria, Va., with a satellite office in West Hartford, Conn., and online at burgessgroup.com.