The current outdated systems cause many errors, delays, and higher costs
Many healthcare insurers were found to be troubled by legacy claims and adjudication systems as they were inefficient and financially bothersome, according to a new report by Info-Tech Research Group.
In its Modernize Your Claims Adjudication System: A Buyer’s Guide, it was revealed that outdated platforms typically plagued by high claim holds, coding errors, reliance on error-prone manual processing, and fragmented IT environments. Because of such issues, problems such as delayed reimbursements, increased administrative costs, and diversion of critical resources from patient care followed suit.
Sharon Auma-Ebanyat, a research director at Info-Tech Research Group, said that despite claims adjudication’s importance when it comes to insurance, it is often handled using outdated systems that give way for a plethora of problems.
“IT and business leaders need to treat modernization as a strategic initiative, not a back-office upgrade,” said Auma-Ebanyat.
Some of the problems that claims adjudication faced were high volumes of claim holds which were caused by coding errors, missing data, and incomplete documentation as well as the heavy reliance on manual processes which increase errors, delays, and administrative costs. Significant financial losses, rising compliance requirements, and data security concerns were also issues that needed to be resolved.
As a solution, the firm’s report detailed a structure roadmap which has three phases.
- Phase 1 – Identify Industry Trends and Shifts: Executives, CIOs, and compliance leaders assess regulatory changes, technological advancements such as AI and machine learning, and evolving market conditions to inform their modernization strategies.
- Phase 2 – Define Business Needs and Capabilities: Business stakeholders, IT operations teams, and clinical leadership determine the specific operational capabilities a modern system needs to deliver, including automation, analytics, fraud detection, and support for value-based care.
- Phase 3 – Analyze Features and Vendors: Procurement leaders and enterprise architects use structured evaluation tools and weighted criteria to compare vendor solutions, ensure interoperability, and select the optimal system.
As a research and advisory firm, Info-Tech Research Group offers reports and advisory services which aid leaders in making well-informed decisions.
