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Publication: Payers & Providers

Publish Date: April 2016
By Craig Kasten


In the 20th century, one of the ways insurance companies demonstrated prosperity and stability was by acquiring land. Architecturally interesting buildings spread across sprawling campuses housed extensive workforces and massive file rooms, all of which were necessary since the bulk of the work was being performed manually.

But we’re no longer in the 20th century. Most U.S. industries, such as retail, telecom, and supply chain, are increasingly doing most of their business in cyberspace using automated systems. Even the staid manufacturing industry is incorporating automation into the mix. Yet in many cases, health payers in particular are still clinging to the old manual model, often driven by the sunk cost of large technology investments.

With the Affordable Care Act bringing health insurance to 20 million more consumers, it’s easy for manual systems to become overwhelmed quickly. Given the high expectations driven by every other aspect of their online lives, neither consumers nor providers will stand for that for very long. At which point, both sides will begin looking for a better option.

There is hope, however. Specific innovations in benefits administration software are paving the way and supplying the technological framework to a future primarily based in cyberspace rather than buildings filled with people. Examples include:

  • Deployment of robust web portals to meet member and provider expectations. Through their interactions with retailers and other industries, consumers have become conditioned to using web-based, self-service portals. Benefits administrators and payers must make this same self-service available to their members and providers. By providing most answers through online portals, payers can focus call center personnel on providing higher value services to members and payers while reducing their costs.
  • 24/7 continuous processing. Most benefits administrators and health plans cannot afford the high overhead around-the-clock staffing requires. By implementing continuous processing technology, benefits administrators and health plans can offer 24/7 processing of incoming claims and authorizations, removing delays and delivering resolution faster.

  • Intelligent claims payment. New innovations are replacing manual tasks with automated, rules-based technologies that will quickly and accurately process 100 percent of all claims edits, and provide immediate authorization for certain agreed-upon services. Additionally, recently-introduced technology is enabling providers to process a prospective benefit claim to determine reimbursement levels and patient responsibility in real time. These technologies are helping organizations prepare for the future by enabling the administration of the new bundled payment formulas that are essential to containing spiraling healthcare costs while turning the often-contentious relationship between providers and payers into a partnership.

  • Paperless administration. New imaging technology and database designs are eliminating the need for massive farms of file cabinets (and the real estate required to house them), replacing them with electronic files that can be securely stored in a fraction of the space, either on-premise or in the cloud. Electronic files make the data easier to search for and access while providing protection against disasters such as fire and flood.
  • Operational transparency through performance dashboards. Filterable, online access to real-time dashboards monitors key performance indicators to deliver greater visibility into financial operations. Driven by powerful performance data analysis engines, these dashboards offer complete operational transparency, helping benefits administrators and health plans improve business efficiency, solve problems and streamline the delivery of benefits. Retrospective data analytics are even providing unprecedented clarity regarding the true cost of pharmacy benefits management, finally giving large employer groups and other plan sponsors a means to bring the skyrocketing cost of prescription medications under control. The ability to obtain multiple supplemental benefits, such as dental and vision, from a single source and administer them using a single technology platform creates further efficiencies.

The reality is the future is coming on fast. And it’s not in gigantic buildings set on picturesque surroundings. It’s in cyberspace. The sooner health payers acknowledge this trend and take action, the better chance they’ll have of making it through this century and into the next.

Learn how you can transform the delivery of health benefits with SKYGEN.