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How to Address Next-Gen Payment, Claims Management Systems

Jim Evans, for HealthLeaders Media, August 4, 2010

A New Class of Systems to Meet Complex Needs
Addressing payors’ existing and future contracting and claims challenges requires a new breed of payment system.  As a starting point, plans need to view contracting as an extension of payment, not just as a negotiation or workflow vehicle. They also need to consider medical policies, payment policies, contract terms, and waste and abuse prevention as part of the payment continuum versus separate pieces. 

Claims can’t be paid in a vacuum.  The audit department is a great place to see if claims performance is really being managed as a continuum. If adjustments are continually being made within the audit department, it is probably because there are inconsistencies along the way.

In addition, plans must look for systems with the capabilities to look across claims and providers.  Systems that cannot accommodate complicated policies must give way so that payors can facilitate appropriate master payment for contracts as they exist today and how they will be in the future.

Payors will have an opportunity to view payment performance more holistically as they start looking at payment policies and contracts for ICD-10 conversions. This can also become an important step towards developing the capability to execute bundled payments and episodes of care with contract terms and payment policy rules that look across facilities and providers. 

The good news is that next-generation payment management systems are available. They can address the payment performance continuum and work alongside the existing claim processing system to automate clinical payment policy, business rules and contract terms, delivering the critical intelligence that is needed for virtually every payment decision.  Payors that implement these new, end-to-end payment management solutions will be able to realize significant savings today through increased efficiencies and reduced penalties and rework. Most importantly, they will be positioned strategically to address the intricacies of emerging bundled payment and episode of care initiatives.

Jim Evans is Vice President of McKesson Health Solutions.

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