Real Time Claim Adjudication – The Next Generation of Claims Submission

As a result of the rising cost of healthcare, today’s patient pays more for their healthcare which puts an increased burden on physicians to seek collections from patients.  This component of a patient’s bill may be due to copayments, coinsurance, deductibles, or non-covered services which can be difficult to collect.  For example, with the onset of today’s high-deductible plans due to rising healthcare costs, a physician may submit a claim only to find out weeks later that payment is the patient’s responsibility.  Such events have increasingly concerned providers of their inability to collect patient charges and adverse patient relations in efforts to do so.

In comes, Real Time Claim Adjudication (RTA).  This capability allows a provider to bill for services at the “point of service” before the patient leaves the office.  A fully adjudicated response is returned from the Payer, detailing the total charge submitted, allowable charges, as well as patient’s responsibility at the time of the service.

The first step is setting up our IT infrastructure and communication channels with specific payers which are offering this service.  The communication setup is not much of an obstacle since RTA uses the same electronic data interchange (EDI) channels as submitting Eligibility requests for some vendors.  Specific RTA communication can be done through web link (as is the case with United Health care) or a B2B software setup as MTBC has done with Availity – 3rd party vendor for Humana and BCBS FL.

Once this process is complete and the option of RTA is deployed to the provider through our MTBC EMR, a Provider can submit the claim to the Payer with a click of a button and within seconds have a response back on whether the claim was adjudicated or not, if so, how much is the allowed amount, estimated payment, and the patient responsibility.

This sort of technology is not available to everyone.  One reason for that is, unlike other industry standardization, such as claims transmission source code and possibly EMR implementation in the near future as is widely expected, RTA is not required to be implemented by the federal government, there are no bonuses or subsidies offered for its deployment  It just provides a very useful functionality and its growth has been fueled by providers asking for it.

However, there are still hurdles the industry faces in implementing the RTA program.   Even though providers are anxious to speed up their payment processes, many of their offices are not yet ready to perform RTA today. Providers have been able to submit “real time” professional claims to Payers but they have to manually key them into an entry screen. Most providers are unwilling to do this duplicate keying. Unfortunately, many providers are unable to take advantage of RTA for a number of reasons.

  • Many providers are not able to have bills ready for submission for at least 2 days.
  • Many providers are unable to submit claims in “real time” because they don’t have the proper practice management setup.
  • Most billing companies are unable to transmit provider claims in “real time” because they also lack the technical capabilities to do so.

MTBC has completed RTA with numerous payers with whom claims have successfully adjudicated in real time for nearly two years running. Some Payers include United Healthcare, Humana, BCBS FL, BCBS Highmark, and BCBS WV.  We are constantly looking into expanding our repertoire with other payers who may be utilizing RTA either directly themselves or through a 3rd party vendor.