The client is a large healthcare third-party administrator (TPA) in Chicago. This company customizes self-insurance benefits solutions for organizations that wish to find the best healthcare plans for their employees and their families. The client’s mission is to enable employers to create insurance benefits that align with their employees’ needs while integrating medical management innovations and cost-control strategies. Vee Healthtek has been working with this TPA as its sole claims vendor for over 16 years.
During Vee Healthtek’s weekly client calls, we learned that the TPA was facing a large problem that it did not know how to remedy. The client informed us that 52% of their claims had to be manually adjudicated, which was incredibly costly and time-consuming. The need for manual adjudication was caused by mismatched information between enrollment data and provider data. The manual adjudication resulted in a fluctuation of quality, as manual adjudication could never be as efficient or accurate as the auto-adjudication process.
When the TPA approached us with this issue, it did not know if or how this could be fixed. It recognized manually adjudicating claims as a huge hassle but was prepared to simply deal with it. Thankfully, Vee Healthtek stepped in and provided an innovative, technological solution that would permanently rid the TPA of manual adjudication. The client evaluated our idea and realized that not only would it work, but it would also save time, save money, and result in correct payments on the first try. This would result in a smoother payment process for its clients, making everyone’s lives easier.
In order for a claim to be auto-adjudicated, the member/patient information and the provider information must match the available record in the claims management system. In this case, the majority of the claims were pushed to manual adjudication because of mismatches in the system. Vee Healthtek’s operations team came up with a solution to identify the correct member and provider records in the claim electronic data interchange (EDI) file. Our IT team built software that compares the information received on a claim against the client’s database. The record’s unique ID is recorded in the claim file and any mismatches are pushed to a manual queue for adding or modifying a provider record. Now, once a claim is loaded into the system, it is automatically verified and can move on to the next stage of service-level validation.
In the case that a match can be neither auto-adjudicated nor manually adjudicated, our solution instantly adds the provider record into the client’s database using the appropriate business rules. Once a match has been made, a unique ID is placed into the EDI file.
Our solution complemented the TPA’s existing system, ensuring that no unnecessary complications were made that would later need to be fixed. Now, mismatched claims are verified against the client's database, and relevant matches are reported back. The provider records which did not exist or did not match are now added to or modified in the system, enabling auto-adjudication to take place.
Because Vee Healthtek had previously implemented a similar system for a different client, we were able to build our solution in a very short amount of time. Previously, we had made this system in two months, but now, we were able to turn the final product around in just one month. Our experience and quick turnaround time greatly impressed our client.
Within two months, the TPA saw auto-adjudication rates increase to 67% from 48%— a dramatic increase that saved an immeasurable amount of time and money. We have continued working with this client over the past four and a half years and have now reached an auto-adjudication rate of 84%.
We were able to create and implement our solution so easily because we understood the intricacies of the client’s business and processes. When the client was talking about its pain points, we were easily able to identify the root cause and come up with a solution. Now that we have helped two different clients with this solution, we are able to recreate it even faster and more efficiently.
