Amazon, Berkshire Hathaway, JP Morgan Target Point of Service Claim Adjudication

POSCA is coming and it’s gonna be really cool……………………….

Amazon, Berkshire Hathaway, JPMorgan: 10 Recommendations for The Future of HealthcareSource: Ernie Clevenger, CareHere, LLC and MyHealthGuide, LLC, 6/21/2018

Ernie Clevenger’s weekly newsletter this weekend appeared an article about The Big Three (listed above) who have banded together to solve health care. The article highlights ten recommendations. The one that caught my attention was Recommendation #9. This is akin to Cash Pay Health Plans which already exist in the market but needs further improvement. Below is Recommendation #9 in the article that explains Point of Service Claim Adjudication (POSCA):

Recommendation #9: Install Real-time Adjudication in JP Morgan’s Banking System

Real-time adjudication means processing a claim and payment at the time of service. Yes, that means receiving the CPT procedure codes, the ICD diagnosis codes, billed amounts, etc. and adjudicating the claim, determining discounts, patient co-pay, deductible and plan obligation … in seconds. All claim and payments are processed and finish before the patient leaves the doctor’s office.

Most self-funded administers (third party administrators (TPA), insurance companies with administrative services only (ASO)) adjudicate claims electronically in the majority. Medical claims are electronically adjudicated 80% of the time, dental 90% of the time, and pharmacy, close to 100% of the time. Moving this adjudication faster to real-time during the patient appointment is possible when certain conditions come together when the following is enabled:

  1. Patient experiences medical need (symptoms, annual, etc.) and resources are instantly available to understand the condition better (EBM) and select the best provider (Healthcare Bluebook, Castlight, etc.)
  2. Online patient appointment scheduler (that sends 270 eligibility request and 271 eligibility confirmation)
  3. Online in-take (to avoid paperwork at doctor’s front desk and speeds appointment processing)
  4. Electronic medical records capturing (EMR) live actions from doctor (CPT, ICD, ePrescribe, notes, etc.)
  5. Practice Management Systems (billing) integrated with EMR and using an agreed-upon charge master (or UCR) that sends claim in 837 format
  6. TPA/ASO claim adjudication system “listens” for 837 for processing and issues electronic remittance and advice.
  7. Financial institution processing remittance activity in real-time via ACH, ETF, or other.

What are the benefits of real-time adjudication RTA) and why is a bank interested?

If RTA is present, then transparency is also available via a “preview”. If the seven steps above can occur within seconds, then a “preview” of the appointment can also occur offering the patient a preview based on estimated procedures and costs. A statistical cost profile will develop by provider, patient, condition, etc., that will “get smart” offering cost transparency to patient and stakeholders.

Evidence-based medicine information will display to patient at the time of making the appointment … and to the clinician at the time of assessing and treatment the patient. Both patient and clinician benefit from real-time medical information customized to the patient, condition, procedure, etc.

Why is a bank interested? Most doctor offices discount their receivables from 3% to 6% for billing and collection to take place. With real-time payments, medical practices might discount more. Compare earnings from these factored receivables (more) compared to credit card processing (less). There are substantial earnings that can be made from processing claims and payments in real-time. Better yet, there are huge savings in medical costs by offering greater transparency at the time of making an appointment.