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Despite the introduction of various electronic and automated claims processing systems and techniques, the administrative burden and cost of processing medical claims continues to rise for many practices, according to an Indiana group practice. "We’re doing everything we can to automate everything we can," says Mary Valdez, manager of patient accounts for the Indianapolis Women’s Health Partnership (WHP). Yet, despite the fact that 80% of WHP’s claims are processed electronically — compared to the 50-60% national average — it still costs this group practice an average of $7.42 to process each claim.
On the up side, the introduction of electronic data interchange (EDI) has cut two weeks off WHP’s claim payment cycle. It now takes two months for the average claim to be paid instead of two and a half months.
Even with EDI, 30%-35% of claims are denied because of alleged errors or missing information, she says. "This claim rejection rate is compounded by the problems our various payers are having with their EDI systems." For example, she says, "our EDI system may show a claim has been accepted by the payer when, in fact, it has been lost or just disappeared."
As an alternative, WHP has moved to a "real-time" claim resolution system distributed by RealMed Corporation of Indianapolis. "With a real-time system, before the patient leaves our office, they are given an automated accounting of how much their insurance covers for that visit, and how much, if anything, the patient owes, without filing any paperwork," says Valdez. "By taking care of the transaction in one setting, with the patient present, and not having to re-open the claim file three or four times, we are starting to move our savings from processing claims into more quality care for the patient."
On a larger scale, Health First, a Melbourne, FL-based health network with specialties in cardiology and women’s and children’s services, has expanded its electronic medical records and claims management to make its use easier for the ambulatory physicians in its 29 clinics.
"This is an active managed care market with many patients who need both primary and specialty care," said Health First spokesman Rich Rogers. For instance, Health First wants any authorized caregiver in the system to have a patient’s records available when the person arrives for a visit. "This assures them they’re being cared for in a close-knit and efficient health care community, and they avoid the hassle of having each provider they see do a new chart work-up," says Rogers.