Where some providers measure their payment cycles in months, Harriet Oster does so in seconds.
Oster, office manager at Lake Murray OB/GYN, has most of her claims to Blue Cross Blue Shield of South Carolina adjudicated in real time. She has used the system for two or three months and submitted claims over the Internet and is getting responses back in five to 10 seconds for most bills.
Oster won't go back to previous methods. Even though she has to enter data again into the practice management system, it's worth the additional effort.
"You know a patient's responsibility right when the patient is at your checkout area," she said. "It's more time-efficient than trying to chase a person to get a bill paid."
Real-time adjudication of claims is getting more attention from providers and payers as pressure increases to reduce administrative costs.
While there are only isolated efforts under way, ASC X12 and the Workgroup for Electronic Data Interchange hope to focus more attention on real-time adjudication by sponsoring the first-ever national conference on Feb. 13 and 14 in Washington.
"There's growing interest on both sides, from the providers and the payers," said Dan Kazzaz, chairman of the X12, who is leading efforts to get real-time adjudication widely implemented.
But to speed adjudication, the industry will need cooperation from other participants, including software vendors, clearinghouses and billing personnel. Agreements will be needed on other communication standards and protocols, Kazzaz said.
"Part of the purpose of the conference is to look at revamping certain pieces of claims operations," he said. "It's not just a matter of data content as it is response to that data. For example, if payer responses are much better and much clearer, it enables people to correct to correct the claim and resubmit it right away."
While ASC has crafted a standard for real-time claims responses, it's not part of the set of standards adopted under the Health Insurance Portability and Accountability Act of 1996. It's important to get a standard widely adopted in healthcare, Kazzaz said.
Blue Cross Blue Shield of South Carolina has been offering real-time claims adjudication through the Internet since May 2002, and so far it has received 7 million claims through its portal, said David Boucher, assistance vice president for healthcare services.
Problem-free claims are adjudicated in eight to nine seconds, he said. The 20 percent of claims that can't be adjudicated immediately are assigned a claim number, assuring providers that the claim has been received and is in the system. The average processing time for providers to receive an electronic claims check is four days, he said.
BCBSSC recently introduced a superbill function that enables providers to enter their top 100 to 200 procedure codes and associated charges. That personalized approach enables providers to click on charges from a menu, rather than keying them in individually.
United Health Group, through its Exante Financial Services subsidiary, is rolling out real-time adjudication capabilities. It's handling about 30,000 claims per week in this way, said John Prince, CEO of Exante, in what he calls a controlled rollout.
United has one common claims platform, which will help the national company handle a variety of insurance programs, interacting directly with providers and obviating the need for an intermediary.
United hopes to make the approach ubiquitous so providers could interact with other payers, and provide back-end integration to feed claims data back into providers' practice management systems, thus eliminating re-keying, Prince said.