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Future-ready claims review: Why automation isn’t enough

It’s time to take your claims review approach to the next level.

May 26, 2023 | 3-minute read

As medical claims management increasingly demands payers’ time and energy, automating the review process may seem like a no-brainer. But as claims grow ever more complex, many automation methods simply aren’t sophisticated enough to handle the job. Here’s why it’s time to take your claims review approach to the next level.

Ask any payer and they’ll likely tell you that claims management is now beset by a host of new challenges. Recent market shifts have brought major changes to the reimbursement landscape: the meteoric rise of telehealth, the growing ubiquity of urgent care centers and the steady expansion of at-home care services, for starters. The result? Claims have become more complicated than ever, and many payers are left wondering how best to tackle the deluge.

Beyond growing complexity, there are many other factors creating a perfect storm of health care evolution. The dizzying array of services offered in most payers’ portfolios (insurers’ average number of product offerings has nearly tripled since 2019)1 has contributed to making claim management more complicated than it once was. The industry’s slow adoption of value-based care models, which would greatly reduce claim volume and complexity, also hasn’t helped. And the increased scrutiny that many payers are engaging in during this time of rising health care costs has slowed the process even further.

All in all, this swirl of new and emerging claims conundrums has left many payers buried in administrative work that often outpaces internal employee capacities. That unfortunate shortfall is unlikely to change any time soon. The global market for health care claims management services is expected to grow by 23.4% annually between now and 2030, ultimately topping out at a total market size of $136.67 billion.2

Transforming claims review is a complex task, and sooner or later, payers will need to take it on more shrewdly or risk falling behind the times — and the paperwork.

Barriers to automating claims review

Fortunately, just as claims challenges have grown, so too have the solutions. For one, many payers have embraced automated tools as a means of spotting claims errors without adding to their internal administrative burden.

However, current automation programs don’t go nearly far enough — and that’s if payers can incorporate them into their claims review infrastructure. Many payers find these programs too cumbersome or expensive to adopt. A July 2022 Optum survey of health plan executives found that for 63% of respondents, the main barrier stopping them from pursuing an automated claims review service was a lack of resources. Another 55% felt that migrating their associated providers from their current system to a new automation tool would be too difficult.3

Even when payers want to pursue claims review automation, they’re not always able to do so. In fact, 50% of the same survey’s respondents found the prospect of automated claims reviews intriguing and had even outlined a strategy for pursuing it but had yet to take the leap. Perhaps that’s why roughly 31% of payers still have entirely manual claims review processes.4 And while automation isn’t the silver bullet many payers may imagine it to be, an entirely manual approach simply isn’t tenable long-term.

Why claims review automation can fall short

Even for payers who use claims review automation as part of their administrative toolbox, going full steam ahead with programs that perform tasks such as processing simple claims or conversing with members via chatbot may not deliver the desired results. To wit: An Ernst & Young report found that “many insurers have experienced suboptimal returns on their initial investments in automation.”5

Why? Because they’ve likely prioritized the allure of technological solutions over the need for understanding nuanced claims and the importance of compassionate customer interactions. As the Ernst & Young report aptly puts it, “To some extent, the culprit has been a technology-first approach that focused on the tangible economic benefits of automation, while downplaying the customer experience upside.”5 The upshot: Efficiency and high-tech speed shouldn’t be the sole metrics of success in a claims management program.

Further, many automated programs simply can’t match the keen and experienced eye of a human being when it comes to the highly complex claims that cross payers’ desks each day. That requires an expert — someone trained in claims management and intimately familiar with the procedures listed, who can target their efforts to the most lucrative and efficient claims, rather than casting a needlessly wide net.

The complexity of modern medical claims is here to stay. As a result, it’s time to streamline and transform the claims review process. Payers should look to strategically combine the best of manual and automated approaches, leveraging a combination of advanced predictive analytics and experienced human interventions. Complexity isn’t the enemy, but it does demand that payers invest in tools that rise to the challenges it presents.

Learn how Optum can help with Focused Claims Review.