Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management News

How Provider Portals Streamline Medical Claims Management

The health payer Capital BlueCross has recently adopted provider portals in order to simplify prior authorization processes and claims management with their provider network.

By Vera Gruessner

Healthcare payers have often struggled to process claims and provide effective customer service in a more streamlined manner due to technological inefficiencies. Insurers have faced challenges with engaging both their consumer base as well as their provider network. However, some vendors are putting forward the provider portal as a way to streamline claims management between payers and medical facilities.

Medical Claims Management

Often, healthcare providers have faced significant inefficiencies in managing their patients’ health plan benefits. For instance, a patient may need prior authorization before a specialist can treat him or her. The provider must send forms to the payer, but often the insurance company must request more information by phone or fax. The provider must then continue sending more data and explanations before the payer is able to give authorization.

This process is called Request for Information and is clearly flawed. However, a provider portal could streamline this process significantly. For example, Capital BlueCross recently chose the Casenet TruCare platform, which shows a provider what type of materials they will need for authorizations and decreases the need for too much back-and-forth.

Casenet LLC announced in a press release today that it will be working with Capital BlueCross to provide disease and case management technology platforms. The payer and vendor are hoping to bring better health outcomes and healthier consumers due to these new technologies. Capital BlueCross is located in Pennsylvania and will be using the new platforms to manage patients with the most complex chronic conditions.

“As more than an insurance company, Capital BlueCross is continually innovating and enhancing the use of technologies to serve our customers with excellence,” said Dr. Jennifer Chambers, Chief Medical Officer and Senior Vice President of Clinical Solutions at Capital BlueCross. “We are pleased to now partner with Casenet as we continue to lead the market in population health initiatives, and engagement with health care providers, to improve care and health outcomes for our customers.”

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These population health management platforms are expected to improve the quality of care received by Capital BlueCross members. Capital BlueCross will also be using the Casenet provider portal in order to streamline the Request for Information process, improve other operational efficiencies, and bring greater provider engagement to the table.

“Capital BlueCross’ forward-thinking approach to delivering integrated care management ensures that their use of TruCare will be a model for member health outcomes that other similar organizations can learn from. By taking advantage of TruCare’s platform approach, Capital BlueCross will have a population health system that supports their needs, and the needs of their diverse member populations, today and into the future,” added Peter Masanotti, Casenet CEO.

Consumer engagement

Along with provider engagement, payers can also use health information technology to boost consumer engagement through expanded communication channels. Consumer satisfaction can be improved through these multiple channels, said Ryan Rossier, Vice President of Platform Solutions at Medullan, in a prior interview.

“It’s a cliche but the term is meeting people where they are. I think that expression, when done appropriately, can actually create a very high sense of satisfaction,” Rossier said. “For example, outbound dialing is still a very common practice of outreach for individuals. Outbound dialing at the wrong times is also still significantly used. What creates high customer satisfaction is actually taking input - let’s say someone calls you between 6 to 8 o’clock. It happens that you have two children and bedtime is seven.”

“If you’re able to capture feedback from an individual that this is not a good time and incorporate that into an outbound contact preference and you then deliver on that promise of not calling that person at the wrong time, then your customer satisfaction is going to increase,” he explained.

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When it comes to medical claims management and automating communication between payers and providers, health information technology will be imperative especially with regard to lowering medical costs and improving quality of care, explained Dr. John R. Patrick, author of Health Attitude: Unraveling and Solving the Complexities of Healthcare, in a previous interview.

“We’ve seen what’s possible when we use Amazon, eBay, and many other successful and profitable websites. We know that Internet technology is very highly scalable. It didn’t used to be back at the beginning,” Dr. Patrick noted. “Technology has evolved. People have mastered the technique of being able to create scalability on the Internet so that an organization can simultaneously serve millions of consumers.”

“I mention that as a backdrop because it begs the question – why can’t we do that in healthcare? I came from a world where you click and something happens. When I got into the world of healthcare, I found there was no place to click,” Patrick added.

Medical claims management and healthcare technology

Without robust technological platforms, payers can have serious problems with medical claims management. For instance, this past winter, the health insurance company Centene announced that it had lost private consumer data of about 950,000 individuals including social security numbers, medical history, and member ID information. With greater privacy and security controls, these type of missteps would not be apparent.

Along with claims management, payers are responsible for well-functioning enrollment processes among their members. One Blue Cross and Blue Shield in Chapel Hill, North Carolina had significant enrollment issues including policyholders who were unable to make payments and others who ended up being enrolled in a health plan they did not choose.

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Investing in the right technologies is important for payers to avoid privacy and security issues as well as obstacles for enrollment. Additionally, engaging the provider network through provider portals could simplify the Request for Information process and streamline prior authorizations for the patient community.

Aligning both member portals and provider portals could bring more engagement for the healthcare industry as a whole. Payers could improve their communication channels with medical providers and their policyholders through adoption of such portals.


Dig Deeper:

How Healthcare Information Technology Boosts Member Engagement

How Health Insurance Mergers Could Change the Payer Industry


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