Payers

Payer Data Integrity and Compliance Solutions

Healthcare payers continue to search for ways to streamline operations and improve profitability. Automated claims adjudication is one area that has the potential to dramatically improve business results. However, with first-pass rates averaging only 40-70%, insurance providers are not reaching the full potential of auto-adjudication. One major reason that claims kick-out or suspend is inaccurate or incomplete provider information that prevents the system from making successful matches.

Many factors contribute to incomplete and inaccurate provider data. At the heart of the issue is the constant changing of relevant provider data, such as addresses, phone numbers, organizational affiliations, and identifiers. Nearly 2% of this critical data changes every month due to address changes alone, so keeping track of millions of unique healthcare providers is a complex, never-ending challenge. Re-credentialing takes place only every two or three years and cannot possibly keep up with all these changes. And with the implementation of the national provider identifier (NPI), these challenges are going to multiply…perhaps spectacularly.

The resulting provider identity errors and incomplete records will make it difficult to accurately match a claim with the appropriate contract. Payers have started to realize that matching technology alone is not sufficient to yield provider data accurate enough to increase first-pass rates. To maximize the auto-adjudication process by resolving conflicts in the identities of providers, payers need a trusted source of provider reference data that is continuously updated and highly accurate.

Learn how Health Market Science payer solutions are:

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