By Bonnie Coburn, VP of Claims Editing

Bonnie is a subject matter expert on designing and delivering solutions that solve complex challenges. As the Vice President of Product, Claims Editing at Zelis, Bonnie brings more than 25 years of experience to the Zelis product team. Focused on improving operational efficiencies and ensuring timely, accurate payments, Bonnie is dedicated to building a comprehensive Payment Integrity solution for our customers.

In my 15 years of Product Management, I have had the opportunity to participate in hundreds of client and prospect calls. The topics discussed on these calls range from discovery, requirements gathering, market feedback, and focus groups to implementation, workflow design, and customer support.

Although every client is different and has their own unique set of strategic goals and challenges, there are often common trends and themes across these conversations. Paying attention to these commonalities allows payers to be confident that their editing solution stays up-to-date and compliant, flexible to adapt to changes in the industry, and tailored to their business needs while reducing spend.

5 questions to ask your claims editing vendor partner

1. How often do you update your content?

Claims editing is a powerful tool within payment accuracy.

Many aspects of content – the regulatory, contractual, and clinical information that underlies edits – are complex and change at a rapid pace. Regulations and legislation change reimbursement guidelines. New innovations in treatments and therapies obtain FDA approval.

Providers are regularly reviewing and negotiating their contracts. These changes and others like them impact the content driving claims edits.

In an industry where nothing stays static, why should your claims editing system?

By asking your claims editing vendor (or prospective new vendor) how often they update their content, you can gain insight into their release and communication cycles, as well as determine how regularly your coding and billing review processes will be enhanced to ensure they are in line with the most recent coding and billing guidelines.

Probe deeper into their release cycle. Ask whether quarterly or bi-annual updates cause any downtime or workflow reconfigurations. Inquire about release training and communication cadence. Asking about the updating of content will help you determine the amount of effort and training for your team that is needed around new edit releases.

2. How are edits concepts designed, developed, and delivered?

Be sure to understand how your claims editing partner develops and prioritizes their concepts. How do they allow for specific business needs configurations? How do your specific needs influence the product roadmap?

Find out how quickly your claims editing workflow updates when regulations and reimbursement guidelines change. Determine how quickly changes in contracts and policy payments are reflected in the algorithms.

Understanding the rationale behind a new edit concept and how it is conceived, tested, and released will provide further insight into how your vendor thinks. The new concept may be based on a pre-determined product development roadmap that is set in stone or influenced by data and trends seen through claim volume and the evolving industry. When it comes to testing, understanding how the edit fires and impacts your workflows will better enable you to process claims edits faster.

In an industry characterized by change and movement, understanding methodologies and testing enhances your ability to stay up-to-date and process claims as accurately as possible.

3. What does implementation look like?

Questions about implementation are related to the question, “Have you worked with my adjudication partner before?”.

These are excellent questions and answers to them can provide you with better ideas about scope, timeline, and the amount of resources required. Additionally, in the event of a first-time integration, these answers could also expand your budget, timing, and considerations on how to phase or roll out the solution.

Implementation questions are key to ensuring the partnership gets off on the right foot.

All too often, a partnership has a lot of excitement and momentum at the time of signing then quickly loses that momentum when it goes into the implementation black hole.

Press your claims editing vendor partner on the implementation process: the level of effort, the number of resources needed, the timeline, etc. You will want to find out how your internal operations model and processes will be affected and how implementations of new lines of business (additional client growth) are handled.

Answering implementation questions will help ensure a smooth transition from signing to implementation to go-live.

4. How do you handle provider appeals?

Provider relationships and communication are crucial parts of your business. Whether you manage your own appeals and inquiries or your editing partner manages them with you, this is a good topic to dive deeper.

Ask what supporting documentation and reports your team has access to so they can confidently speak with the provider and see how escalations for provider inquiries are handled. You should also find out what other support is offered.

Make sure you understand what the communication and training curriculum is and how your vendor supports the findings. Remember that your claims editing vendor partner is an extension of your brand and ensuring the least amount of provider abrasion is important. Ask the detailed, scenario-based questions to best protect your brand’s reputation while ensuring optimal savings are identified and protected.

5. What does your customer support model look like?

Claims editing tools apply rules (or edits) to claims to ensure compliance with clinical and regulatory guidelines. These tools are a crucial part of the Payment Integrity workflow and provide a lot of benefits but also require proper “care and feeding”.

Constantly changing regulations coupled with the need to adapt to the personalized needs of the client can result in a highly customized solution. This can often be difficult to maintain and support.

The long-term relationship and support of the product is a key part of optimizing the solution.

Your claims editing vendor partner should tell you how questions for edits – from both internal staff and providers – are handled.

Ideally, your vendor will have specific staff assigned that understand your specific needs and will communicate changes in software, edits, and content both to you, the payer, and to your providers.

Wrapping it all up

As we at Zelis challenge ourselves to develop a customizable and flexible solution for your unique needs, I challenge you to look at your current claims editing workflows and ask this bonus question: “What else can we be doing?

It is this question that helps all of us think outside of the box to bring holistic solutions to our clients. Because when we treat each claim like the dynamic patient story it is, we move the industry closer to paying for care, with care.

Looking for more claims editing content? Check out a recent Zelis article: Best Practices for Identifying Claim Errors Prepayment.