Optum Advanced Communcation Engine

Proactively identify claim errors prior to adjudication

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Optum Advanced Communcation Engine Video

Claims automation has revolutionized the healthcare industry. With the advent of electronic data interchange and more streamlined claims, the insurance industry enjoys a clean claims rate of nearly 80%. But with new industry pressure to further reduce administrative costs, is there more we could do?

A minor coding error or duplicative claim or service line from a provider can mean increased costs for both you the payer and for providers. Administration costs can be decreased if we can increase the percentage of error-free claims.

Erroneously coded claims or redundant service lines can infiltrate the adjudication platform. Notices arrive to providers and patients that claims were denied or duplicative and the administrative costs begin to build. Secondary claims, patient statements, phone calls, mailings, tertiary claim submissions, and appeals. An average cost of $6 per claim for the payer—and $25 for the provider*.
* Medical Group Management Association study: “The Costs to Physician Practices of Interactions with Health Insurance Plans,” 2009.

A large percentage of these coding errors are repairable by the providers in their existing claim streams. But what if you could move many of your coding edits forward into the EDI stream to allow the providers to repair their own errors without any additional administrative effort? How would that impact your administrative costs and the level of transparency you have with your network providers?

Advanced Communication Engine from Optum helps ease administrative burdens by preventing erroneously coded claims from entering your adjudication platform by empowering providers to self-repair coding mistakes. The automated solution is integrated directly into your gateway or transaction delivery point and doesn’t require changes to your existing adjudication processes.

It’s the first proactive claims editing solution that allows you to push certain-to-deny claim errors back to the provider to repair before they get denied in your system. By using a 277CA transaction, the provider will receive an alert via their existing claims aggregator, Practice Management or HIS system. What could take weeks and arrive with varying velocities in a cryptic 835 denial message can now happen in near real-time (at the speed of EDI), with an automated, easy-to-understand description of what the Provider needs to fix in order to submit a clean claim. The Provider may choose to override these alerts if they wish to send their claims in their original form.

That’s the value of Advanced Communication Engine: Enabling providers to repair errors consistent with your coding protocols, reducing your administrative costs, improving your medical loss ratio, and bolstering your relationship with your network providers. Fewer phone calls, fewer appeals, and fewer delays. It’s a true win win for both parties.

And with Advanced Communication Engine in place, there are further opportunities to improve your operations by verifying patient eligibility, providing notification of claims that require attachments, and detecting patterns of provider fraud and abuse.

With Advanced Communication Engine, cleaner claims are within your reach.

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