Profiler Magazine

Real-Time Validation & Collaboration

It is amazing that in a country where technology consumes our daily lives that any health plan would still be paying inappropriate claims. More frustrating is their approach to chasing these overpayments hoping to recover pennies on the dollar. Alas, that is exactly what is happening. Many health plans are stuck in a quagmire. There’s a need to pay claims fast through auto-adjudication to meet each state’s prompt pay laws while also taking steps to pay the right amount of money the first time around. Not long ago I met with a claims operations manager for a health plan who bragged of paying a ninety-five percent auto-adjudication rate on first pass claim payments. After hearing about their overall process and better understanding the amount of recovery efforts they were going through I thought, “Who wants to get better at paying bad claims faster?” And still today I wonder how much more effective these plans would be if they got their head out of the sand and decided to play a part in the twenty-first century.

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