When the topic turns to real-time claims adjudication, Bryan Braswell gets to the point-as fast as the technology itself. He's not interested.

Braswell is director of business services at OrthoCarolina, a large physician group based in Charlotte, N.C. With 180 physicians, 100 physical therapists, and some 80 other care extenders, OrthoCarolina sends the lion's share of its claims to less than 10 payers. The idea of processing a claim instantly-so the practice would know expected reimbursement and its patients would know their obligations before heading home, all within seconds of submission-would seem to be appealing. After all, real-time adjudication is designed to streamline both the revenue cycle for the provider and turn the health care encounter into a more customer-friendly transaction for the patient, one similar to common retail transactions where the cost of goods and services is known immediately, not the health care norm of days or weeks later. But Braswell's not buying. "If it led to real-time payment, we might consider it," he says. "But I don't see the value unless you are getting the money back at the same time."

Braswell has plenty of company. Real-time adjudication has been bandied about for years as the ideal insurance transaction for physician practices and outpatient service providers (even die-hard champions acknowledge that inpatient claims are far too complicated to document, let alone process prior to discharge in real-time). Yet the technology has little uptake in the industry. Despite a multitude of potential benefits (improved cash flow, decreased operational costs, and less patient confusion over bills), only a miniscule portion of health claims are adjudicated while the patient is still on-site.

Patients routinely wait weeks to find out what they owe; providers are stuck with expensive collections efforts; payers must contend with the expense of resubmitted claims. No one is particularly pleased with the health care revenue cycle.
So why hasn't the industry made greater headway toward real-time adjudication? The reasons for the lack of uptake are as varied as the revenue cycle is tangled. Workflow issues among providers, compounded by their inadequately architected practice management systems; overly complicated claims management systems (and policies) among payers; and the very complexity of health care billing overall all stand in the way.

Gary Baldwin’s feature story in the June issue of Health Data Management looks at the present state of real-time adjudication and attempts to build alternatives that address the problems that real-time targets.

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