Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management News

Key Ways Payers Could Improve Medical Claims Management

In order to enhance medical claims management, healthcare payers will need to implement new technologies including provider portals.

By Vera Gruessner

Medical claims management is a key aspect of the payer-provider relationship. However, medical claims management tends to include multiple challenges for both payers and providers. Some of the problems stem from a lack of training in medical billing among providers who are stretched thin learning about value-based programs, the physician quality reporting system and other regulatory changes while attempting to manage patient care.

Health Information Exchange

Below we outline key solutions for medical claims management that health payers may need to incorporate in order to strengthen the payer-provider relationship.

Medical device identification

In order to improve patient safety and reduce wasteful spending, health insurance claims may need to include medical device identification data specifically which product is implanted, according to The Pew Charitable Trusts.

Health insurance claims do contain information about the type of surgery or medical device implantation procedure was conducted but lack information about the actual product used including data on model and manufacturer. However, the Food and Drug Administration (FDA) does regulate medical devices using a unique device identification system.

“Unfortunately, right now, claims data lacks any information on specific devices that are used in care,” Dr. Josh Rising, Director of Health Care Programs at The Pew Charitable Trusts, told last April. “The claims data might indicate that a patient received a new hip or had two stents placed, but they don’t have any information on the specifics of which stent or which hip was used.”

READ MORE: How Payers, Providers Could Streamline Medical Claims Management

“If there’s a question about the performance of a product or if you’re trying to understand which hips are providing better care or what devices might have safety problems, right now, you’re unable to use claims data to look at those questions  in the way that you could use it for drugs.”

By requiring more information about medical device identification within medical claims, payers could reduce wasteful spending associated with multiple surgeries if a device is found defective. These steps should also lead to improved health outcomes and a check on patient safety.

Provider portals

Another solution for improving medical claims management is to incorporate provider portals, which may streamline claims processing. Oftentimes, members need prior authorizations from health plans before seeing a specialist. The prior authorization process is often complicated with payers and primary care providers sending forms by fax and spending countless hours on the phone. Provider portals, however, streamline the prior authorization process.

Capital BlueCross is one payer that has adopted a provider portal in order to streamline medical claims management. These systems show providers exactly what documents and materials are needed to complete a prior authorization.

Innovative technologies

Another way payers could improve medical claims management is through the adoption of new technologies. In particular, automation technology could be a useful method for streamlining claims processing between payers and providers.

READ MORE: Risk Adjustment Affects Plans on Health Insurance Exchanges

“Information technology is an imperative for payers. From a core administration perspective, the core responsibility of a health plan or a payer is to finance healthcare,” Kimberly Branson, the ‎Vice President of Business Architecture & Strategy at Medica, told last February. “The way that it’s done is pretty complex between the payer and the provider. Having information technology that helps to automate workflow and automate the transfer of information within and in-and-out of a health plan is critically important.”

Additionally, payers will need to ensure their data security protocols are effective in order to avoid the downfall Centene experienced last winter where it lost six hard drives filled with private member data.

One way for payers to have a clearer view of their members’ use of healthcare is to partner with a health information exchange entity. Working with such organizations will enable insurers to more quickly and effectively share claims data with providers and create more efficiency in their medical claims management. For example, one study published in the American Journal of Managed Care found that using health information exchanges reduced the rate of repeated medical images in 90 days by 7.7 percent.


Managing medical coding and keeping documentation accurate and complete is necessary for keeping the healthcare revenue cycle efficient. Health insurance companies could provide more training materials for their provider networks to learn how to improve clinical documentation. For example, on its website, Humana provides vast resources for clinicians to document diagnoses codes accurately.

In order to improve clinical documentation, physicians may need to focus on making small changes to their behaviors and habits. For instance, the medical team at the Summit Healthcare Regional Medical Center made changes to their clinical documentation by targeting small details. Over time, the small changes added up to a much larger overhaul of their medical documentation procedures.

READ MORE: 3 Strategies to Follow in Value-Based Care Reimbursement

Payers would benefit from following the tips above. The advice could streamline their medical claims management and improve their payer-provider relationship.


Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

How Health Insurance Mergers Could Change the Payer Industry


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