Real-time Claims Processing in Healthcare: Leveraging Stream Processing Technologies for Faster Payment Adjudication

Authors: Veeravaraprasad Pindi

Country: India

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Abstract: This paper discusses strategy options that can help to streamline claims processing for Medicare applications. The traditional batch-oriented approach to claims adjudication does not enable real time processing. Recent advances in stream processing technology can address this gap. In this paper, we present the architecture of a real-time claims adjudication system and describe the implementation and evaluation of a prototype using Apache Kafka and Apache Flink. The prototype system can process 800,000 medical claims and achieve adjudication in one second. The results show that stream processing technology can enable sub-second real-time claims processing [1]. As the volume of patient medical services increases, sub-second real-time claims adjudication will become even more important to relieve provider staff waiting for the results as patients are checking out and to ensure a good patient financial experience. Healthcare spending in the United States is estimated to be a staggering $3.6 trillion in the year 2018. Two-thirds of this tremendous sum are attributed to non-commercial and commercial health insurance. In order to better handle the surge in healthcare spending, an increased usage of high deductible health plans has been observed [1]. As patients are taking on more financial responsibility for medical services, there is a growing interest in ensuring that patients comprehend their financial obligations at the point-of-service. To make this possible, insurers must have the capability to promptly adjudicate medical claims. Health insurance claims represent requests for payment, or requests for review of payment for services provided to the beneficiaries of a healthcare program. Healthcare claims are submitted by providers who deliver services to patients, and by patients who have incurred eligible charges. Healthcare payers apply various edits to the submitted claims to verify the eligibility of the service, the accuracy of the charges, and compliance with the benefits offered by the patient's health plan. Due to the complicated medical insurance options offered to employees, the claims processing times can be somewhat extensive in order to review the medical claims [2]. Today, the majority of claims are addressed through batch solutions, which require several hours or even days for their completion. A rise in the need for real-time claim adjudication is experienced due to efforts by the healthcare providers who wish to verify whether a patient’s claim is valid and the amount the patient is expected to pay before being treated. Also, there are more expectations to simplify the claims adjudication automation supported by advanced technologies which include artificial intelligence. This incorporates; the use of big data and predictive analysis to indicate potential problem areas with regards to claims and risk analysis then prioritizing them for examination. Real time claim adjudication seems to offer the best solution since it seeks to ease the burden of provider’s revenue cycle as well as has the potential of enhancing patient satisfaction. Apart from giving more eligible and efficient information on the financial responsibility of patients, real-time claims processing can also assist in checking fraud and abuse by detecting suspicious claims. Thus, strategies to handle and adjudicate claims in real time will persist as the healthcare field advances and becomes more reliant on technology and innovation. Claims adjudication involves making a decision to approve or disapprove a claim and to pay for the service out of the health plan funds. Adjudication of claims entails several stakeholders- the member (patient), provider (doctor, hospital), and the health plan (insurer) [3]. The process encompasses an assessment of a member’s enrollment, medical necessity along with the benefits that are covered. All the health plans have a certain Medicare required time frame for the claims and the time taken for the claims adjudication. To achieve these and also reduce the amount spent on administration, health plans are aiming for faster, preferably real-time, claim adjudication. This paper seeks to explain how this event stream processing technology can be used to enhance healthcare claims adjudication in real-time [4].

Keywords: Healthcare Claims Processing, Medicare, Batch Processing, Efficiency, Error Reduction, Artificial Intelligence (AI), Machine Learning (ML), Blockchain, Claims Automation, Data Validation

Paper Id: 1773

Published On: 2014-08-22

Published In: Volume 2, Issue 4, July-August 2014

Cite This: Real-time Claims Processing in Healthcare: Leveraging Stream Processing Technologies for Faster Payment Adjudication - Veeravaraprasad Pindi - IJIRMPS Volume 2, Issue 4, July-August 2014.

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