Every delayed healthcare claim carries a significant cost. Providers face reimbursement delays, patients grapple with financial uncertainty, and insurers expend valuable resources rectifying errors. The root causes for denials are varied, ranging from missing or inaccurate claim data and coding errors to incomplete patient information.
The common thread underlying these challenges is clear: inefficient and fragmented communication between payers and providers. In a session sponsored by Optum at the 13th Annual Becker’s CEO + CFO Roundtable, Kevin Cahalane, Client Partner at Optum Advisory, and Puneet Maheshwari, SVP Reimbursement Solutions, Optum, brought together healthcare leaders to discuss potential solutions to the financial and administrative hurdles of claim settlement.
Four key takeaways:
1. The siloed approach to payment integrity and revenue cycle management is unsustainable. According to Mr. Maheshwari, around 15% of healthcare claims are initially rejected and require reevaluation. To address the staggering 500 million claims reworked annually, two massive industries have emerged: revenue cycle management (RCM) on the provider side and payment integrity on the payer side. “These industries spend around $350 billion to move money between payers and providers,” Mr. Maheshwari said.
There’s a significant opportunity to better align these functions, as they share the common goal of ensuring claims accurately reflect patient visits and are paid correctly the first time. By integrating payment integrity principles into the RCM process, the focus shifts from a reactive system (responding to denials) to a proactive one. Performing checks for accuracy and compliance before claim submission catches potential errors early, accelerating payments and improving cash flow.
2. Real-time transparency is key to addressing root claims-processing problems. The current siloed approach between payers and providers inevitably leads to rework. Real-time communication can dramatically enhance the efficiency of the claims process, fundamentally transforming how these parties interact.
Mr. Maheshwari described Optum’s innovative approach where AI agents act as scribes during patient visits, identifying documentation gaps for providers. Once providers approve the visit documentation, the AI agent autonomously codes, creates a claim, and initiates a real-time inquiry with the payer to verify its completeness and accuracy. The Payer responds in real-time with patient eligibility, coverage status, patient financial responsibility, and any expected denial reasons all before the patient leaves the facility. Currently a mid-west health system is piloting the real-time data exchange piece of this model for outpatient radiology and cardiology and has already seen fewer administrative errors.
3. Technology and process redesign drive real-time claim settlement. From a technology perspective, Optum looks at every workflow through three lenses:
- From Rules to Reasoning: Shifting from rigid, rule-based systems to more intelligent, reasoning-based platforms.
- From Manual to Agentic: Transitioning from manual processes to automated, agent-driven transactions.
- From Batch to Real-Time: Replacing delayed batch processing with immediate, real-time operations.
To facilitate these shifts and enable real-time interoperability between payers and providers, Optum recently launched Optum Real. “This set of APIs creates real-time transparency between payers and providers, starting with UHC,” Mr. Maheshwari explained. “We are engaging with virtually every payer in the country and collaborating with major EHRs to create workflows that significantly reduce overhead between payers and providers.”
4. Technology-enabled transparency offers new solutions to systemic issues. In healthcare, fragmentation and distrust between payers and providers have unfortunately become the norm. Given this historical friction and silos, some roundtable participants, while excited about the promise, expressed skepticism about the real-world adoption of claim settlement innovations.
However, Mr. Cahalane suggested that technology could “puncture a hole in the dam that has created perverse incentives in healthcare.” Mr. Maheshwari echoed this sentiment, emphasizing, “Collectively creating awareness and dialogue is the only way to solve this two-sided problem. If we can break the silos and create transparency, it will generate immense value for all.”
The path forward: A collaborative future for healthcare claims
The insights from the Becker’s CEO + CFO Roundtable underscore a powerful vision: by embracing real-time transparency, advanced technology, and collaborative partnerships, the healthcare industry can move beyond its current inefficiencies. Optum’s initiatives, like Optum Real and its AI-driven solutions, are paving the way for a future where claims processing is not a source of friction but a seamless, accurate, and timely exchange that ultimately benefits providers, payers, and most importantly, patients. This shift represents a significant step towards a more integrated and patient-centric healthcare ecosystem.
