Humana’s Real-Time Claims Adjudication Assisting Physicians

Humana Inc. reported the launch of its integrated real-time claims adjudication process that will reportedly simplify administrative tasks and help physicians obtain payment for services from patients more quickly.

This solution comes as high-deductible health plans (HDHPs) reportedly continue to gain popularity with employers. Humana’s real-time claims adjudication integrates a number of partners and technologies that submit claims and return the adjudicated claim by calculating the exact dollar amount of most health plan members’ financial responsibility before the member leaves the doctor’s office.

“This new capability is a much more realistic and efficient approach than any other options that are available to physicians today,” said Bruce Perkins, Humana’s senior vice president for national contracting. “It replaces other alternatives that involve time-consuming administrative office hassles, such as duplicative, manual keying of claims information, with one-time entry, followed by an instant swipe of a debit card.”

Those other alternatives reportedly require the patient information to be manually keyed twice, first into a computer or card terminal – much like each grocery item’s bar code would have to be keyed in — then into the practice management system. That method is reportedly often time-consuming and can lead to errors in data entry.

Currently, physicians send claims to Humana either electronically or through the mail. The claims process has to be “adjudicated,” which takes into account the specific member’s benefits and health plan discounts. Once the claim is paid, doctors must then bill the member for the balance, reportedly resulting in delays of weeks or months before the physician gets final payment from the member.

For most of its members who hold the HumanaAccess Visa debit card, Humana’s real-time claims adjudication reportedly offers a more simplified administrative approach than available options today.

Providers using one of the participating practice management solutions enter the claim once in the practice management system.

The claim is submitted electronically to Availity, LLC, Humana’s primary gateway for the submission of claims. Availity immediately sends the claim to Humana for adjudication. Humana’s system returns the adjudicated claim through Availity to the provider’s office. Within 30 seconds, the provider’s office knows exactly what to charge the Humana member. It can be instantly deducted from his/her health care savings account (HSA), health reimbursement arrangement (HRA) and/or flexible spending account (FSA) using the HumanaAccess Visa card. Humana’s portion of the claim is paid in the normal weekly cycle for electronic claims submission.

Humana is currently working with MacGregor Medical Center in San Antonio, along with others, to provide the primary care practice with real-time claims adjudication capabilities.

Throughout 2006, Humana will roll out real-time claims adjudication to other providers across the country. To encourage acceptance of this opportunity, Humana is also working with ZirMed Inc. to develop solutions that provide real-time claims adjudication capabilities without costly integration with the providers’ information or practice management system.