At Gem we built an ecosystem in partnership with Capital One allowing for people to plugin and provide transparency and a network today that is very closed door. By entering the network, multiple parties can automatically know how a medical claim will be submitted and what rules it will validate against. No more build out logic, cross your fingers, and hope you get it right.
The Problem
The claims solution we created takes aim at three of the toughest issues confronting the healthcare industry. The first is the lack of real-time transparency into health claims transactions involving providers and payers; then there is the amount of time it takes for providers to get paid for their service. Thirdly is the slow rate of provider reimbursements because of the time it takes to generate and deliver the patient's Explanation of Benefits.
“As reimbursement demands go up, payers reduce coverage and increase premiums. The cycle continues as the broken billing relationship is strained by inefficient technology and changing regulation.”
The Solution
We attacked the problem to shorten the decision time for approval of a claim from a payer to the provider so the provider can bill the patient as quickly as possible. The conversion cliff of patient payment for their responsible bill (not just their co-payment) falls off at 60 days, we proved that this system could work in minutes while a patient is still in the waiting room.
To do so we employed the following components:
Identities and Pointers
We created resource lists of schema define patients, providers, and payers that served as the routing mechanism for transference of data and access controls and permissioning.
Claims Rules Validation and Structure
Currently, for a Provider to integrate with a Payer's reconciliation systems it necessitates a 100 page PDF for detailed rules on their integration points that differ from the standard EDI 835/837 data payload for the transference of medical claims. Here we created the defined structure for medical claims as well as associated ICD and CPT codes for diagnosis and procedure codes respectively. Along with this structure we distributed rules validations for allowable diagnosis and procedure code pairings to the network for distributed logic automation.
Claim Approval Automation
Based on configured claim variables and payment amounts we instantiated automated claim approval steps for speed of reconciliation based on the rules sets of claims that easily pass basic validation rules and are low value claims below standard risk thresholds.
Payment Settlement
Payers can then create bulk payments on their contractual terms while providers have visibility into committed revenue which currently doesn't happen in today's EHR and EMR systems. Patients can receive their explanation of benefits based on approvals in almost near real time to pay not only their co-pay but their patient responsibility while still in the providers office.
Conclusion
Within this new system and structure of automated rules validation and document routing we provide speed for reconciliation, trust amongst parties, as well as predictable revenue forecasting among other strategic benefits for Capital One and their health book of business.