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Bridging the Gaps: How Electronic Payments Can Optimize Payer, Provider, and Member Experience

Administrative burden costs the US healthcare system hundreds of billions of dollars each year.1 The majority of the spending is attributed to payer overhead, which has grown throughout the years despite continued adoption of electronic processes.

Electronic claims management, such as Automated Clearing House (ACH) and Electronic Fund Transfer (EFT) payment, has been on the rise, especially since the implementation of the Affordable Care Act, which mandated the development of operating rules pertaining to EFT payment and other electronic communications between payers, providers, and members.

These electronic processes are designed to streamline claims management and payment to make the healthcare experience easier for all involved while reducing overhead and other administrative costs. But many of these processes have failed to achieve their goals.

First, the claims management and payment process today is still largely manual, hinging on who is paying and who is getting paid. The healthcare industry at large has yet to coordinate an automated approach to submitting, verifying, and paying out claims across payers and providers. The piecemeal approach to electronic claims management and payment has not only created more headaches for payers and providers trying to reconcile accounts, but also for patients who may receive an unexpected balance bill and/or struggle to connect with the right person to understand their financial responsibility for care.

Second, even existing electronic claims management and payment workflows have their flaws. For example, many payers have implemented ACH or EFT payment. However, this method of payment is largely reserved for high-volume providers or high-dollar services. Each payer may also have their own portal, leaving providers to manage dozens of different electronic processes in order to get paid for all the patients they see and bill those patients correctly. This is yet another point of friction between payers and providers, especially after the enrollment process. In order to get paid electronically,
providers already have to jump through hurdles to enroll in electronic payment methods.

The state of electronic claims management and payment leaves significant gaps between the key players in healthcare: payers, providers, and members. Bridging these gaps will require coordination, and just as importantly, an automated solution that reduces the burden across all three stakeholders.

This whitepaper explores the challenges you’re facing with claims management and payments. It offers ideas to help reduce costs, streamline operations, and improve the payments experience for all stakeholders.

1 Himmelstein, D. U., Campbell, T., & Woolhandler, S. (2020). Health care administrative costs in the United States and Canada, 2017. Annals of Internal Medicine, 172(2), 134.

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