4 Ways Effective Claims Adjudication Can Control Healthcare Costs

National health expenses in the United States continue to rise at an alarming rate. In 2021, healthcare costs reached a staggering 4.2 trillion US dollars, representing 17.4% of the country's GDP*. The COVID-19 pandemic has strained government budgets further, contributing to increased healthcare expenses. In addition, job losses and illnesses caused many to lose employer-sponsored health insurance. For this reason, the country is witnessing a surge in enrollment in public health programs that often offer coverage beyond what traditional Medicare provides. This upward trend placed a significant burden on patients and health plans and affected the overall economy as well. 

However, an advanced claims adjudication process can ensure accurate and efficient processing of healthcare claims, ultimately saving overall healthcare expenses. Read on to find out more about claims management strategies for cost-effective results.

The Challenge of Rising Healthcare Costs 

A recent benchmark study by Zelis highlighted that only 13% of respondents showed leadership in implementing effective cost-containment measures in healthcare. It implies that there’s still a lack of perceived realization about cost containment in the healthcare sector. The study also reported that inaccurate claims management and processing, improper coding, duplicate billing, and inclusion of unnecessary healthcare services can all lead to overpayments and significantly impact healthcare costs.

4 Powerful Claims Adjudication Strategies for Cost Savings

1. Leveraging Automation 

Manual claim processing is time-consuming and more prone to errors. A study on cost-containment in healthcare states that approximately 8% of payment accuracy professionals still rely on a fully manual claims adjudication process. This data reinforces the importance of automation strategies for streamlining workflows and reducing errors.

Health plans should consider automating the following tasks in the claim adjudication process for error-free output:

• Data Capture: Avoid manual data entry from paper claims to reduce errors and accelerate processing times.
• Eligibility Verification: Automate eligibility checks to ensure claims are only processed for covered services. 

Discover how these two scalable solutions from a Florida-based third-party administrator called Mirra Health Care can revolutionize your claims adjudication process:

• ClaimsLite: Designed for effortless entry of paper claims, Mirra’s ClaimsLite solution automates data capture, reducing the risk of human error and accelerating processing times. Claims Lite converts the paper claims into an EDI file. Both Paper and EDI claims go through a validation process to ensure the claims data is correct. 
• ClaiMaster: This solution handles the adjudication of paper and EDI claims mandated by the Centers for Medicare & Medicaid Services (CMS). Mirra’s ClaiMaster automates a wide variety of tasks, including eligibility verification, benefit application, and payment calculations, to reduce manual workload.

Read more: Optimize Claims Processing with Mirra's Real-Time Adjudication | Mirra HC

2. Minimizing Denials with Accuracy 

Inaccurate claim coding is the primary contributor to claim denials. Here's how healthcare plans can prioritize accuracy in the claims adjudication process:

• Invest in Editing Software: Implement robust editing software with comprehensive editing libraries, including the latest CMS edits. Mirra’s built-in editing software has over 40 million edits, including the latest CMS NCCI edits, to ensure that the claims comply with coding regulations.
• Provide Real-Time Feedback: Real-time edits and feedback during claim submission allow for early identification and correction of coding errors. This can prevent unnecessary denials and further streamline the claims adjudication process by reducing administrative costs associated with rework.

Read more: Understanding Preventive Strategy to Navigate Denial Management | Mirra HC

3. Prior Authorization for Informed Decisions 

Prior authorization is a process where a health plan requires approval before certain services are rendered. Mirra Health Care's integrated Utilization Management module supports prior authorization processes. The module allows health plans to establish clear guidelines for services requiring prior authorization.

4. Data-Driven Insights for Informed Action

Data is a powerful tool for identifying areas for cost optimization in the healthcare claims adjudication process. Consider leveraging services that analyze historical data to identify patterns and trends in utilization and potential areas for cost savings. In addition, utilize data analytics to identify potential fraudulent activity and prevent improper payments.

Mirra HealthCare: Your Partner in Streamlining the Claims Adjudication Process

For cost-effective, customized claims adjudication solutions, contact Mirra Healthcare, a Florida-based Third-Party Administrator that offers a holistic and comprehensive approach to providing cost-effective claim management solutions. Our claims adjudication process empowers health plans to achieve significant cost containment through advanced automation and editing tools, real-time built-in compliance checks, data-driven insights, and more.

Why Health Plans Prefer Mirra’s Claim Adjudication Solutions 

• Customized solution: Mirra’s claims management solutions are tailored to fit the specific needs of each health plan. This means we integrate our claims adjudication solutions with existing systems and handle different claim formats (paper or electronic) without requiring extensive modifications.
• Minimal error: Automation reduces manual data entry, which is a major source of errors in claims processing. This can save health plans’ time and money otherwise spent correcting mistakes.
• Cost-efficiency: Faster processing and fewer errors can significantly reduce administrative costs for health plans and provide a better return on investment.
• Improved turnaround time: Mirra automates claim processing to reduce the time it takes for providers to receive payments. This can improve overall efficiency and satisfaction for both health plans and providers. Contact us today to schedule a demo and explore how our solutions can help you achieve significant cost savings!

*Statista. “Health Expenditures in the U.S. – Statistics &Amp; Facts.” Statista, 18 Dec. 2023, www.statista.com/topics/6701/health-expenditures-in-the-us/#topicOverview.