Can Medical Claims Processing Help Battle Certain Uncertainty? ACA, MLR & RPA
July 12, 2018
By Randy Dufault
Consider this. Recent headlines report that the Centers for Medicare & Medicaid Services (CMSs) is freezing billions of dollars of payments to insurers under the Affordable Care Act's risk-adjustment program.
The decision to freeze the risk-adjustment payments arose out of a court decision regarding the formula to determine risk-adjustment payments to insurers covering sicker patients. Without that information, insurers cannot determine their medical-loss-ratio as required by the ACA.
Yet on the same day that news broke, industry publications also reported that at least some insurers have had plans to expand ACA exchange participation. As CMS, Insurers, and the courts sort out what happens next, one fact has become clear: uncertainty has become a fact of life for insurers issuing individual plans under that ACA.
It may come as a surprise, then, that technological advancements may help claims processing combat some of health insurers’ uncertainty.
Advancements in Robotic Processing Automation (RPA) are allowing insurers at the leading edge to use technology investments both to reduce costs and become a source of certainty—and key data. By using digital business transformation solutions and process automation robots, RPA lets insurers:
- Eliminate redundant/repetitive work
- Enable higher productivity
- Align talent to task
- Create faster claims processing through-put
- Speed resolution of standard and non-standard claims issues
- Meet external CMS processing deadlines
More importantly, RPA also allows claims processing to become a key source of data for determination of the information that matters most for things like risk-adjustment and MLR.
Ceci Connolly, president of the not-for-profit Alliance of Community Health Plans, attributes the previous success bigger plans like the Blues have had with risk-adjustment to the data sets (and reserves) they have to devote to figuring out the formula. "If you are a smaller plan, you may not have squadrons of experts at your disposal to capture every bit of that risk," Connolly said.
Now, no matter the insurance company’s size, the data-capture capabilities of medical claims processing solutions that use RPA can help level the playing field by providing insights about claims, losses, and other vital data needed to communicate total risk. Helping—at least within the company—define and share what is known about existing risk, thereby certainly battling uncertainty by clarifying exactly what is certain.
Randy Dufault is a Director of Digital Transformation at Genus Technologies helping insurance industry clients use RPA and solutions like Genus' ActiveClaim to conquer the first mile of digital transformation and gain ROI, data, and certainty from medical claims processing.