Error rates for paid medical claims by commercial health insurers have dropped significantly in recent years to approximately 7%. This still costs the U.S. healthcare industry over $40 billion/year.
Goals and Objectives
Improve speed, cost, and quality of claims submission and adjudication.
Balance economic requirements with legal/regulatory requirements, individual jurisdictions, and medical specialties.
Software rules engines, macros, scripts, and analytics that can be overlaid on manual processes or on inefficient software workflow applications (These often require reengineering of existing processes. Ultimately, cognitive analytics will be automated.)
Use Case Summary
Paper and electronic forms are submitted by hundreds of thousands of provider organizations to hundreds of commercial and government payers for payment using arcane rules, aging software, and often manual processes. Human touches can be reduced, and processes can be improved to speed error-free payment.