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In times gone by, claims processing was straightforward - submit, review, approve or deny, pay. But that was when health plans had fewer members, simpler benefit structures, and regulatory requirements that changed annually, not monthly.
Today, managing claims has become much more complex. The average health plan processes three times more claims than it did five years ago. Each claim involves more complex decision paths, multiple regulatory checkpoints, and higher patient expectations for faster turnaround times. As a result, many health plans are finding themselves struggling to keep up with growing demands while using outdated systems that were never designed to scale.
Modern claims adjudication software addresses these challenges head-on, automating complex processes, ensuring regulatory compliance, and dramatically improving processing speed and accuracy. But the transformation goes beyond operational efficiency - it’s strategic. By empowering health plans to compete effectively, control costs, and improve stakeholder satisfaction, modern claims adjudication software is a game-changer.
The Strategic Impact of Legacy Claims Processing Systems
Traditional claims processing systems create challenges that extend far beyond operational inefficiency. Health plans relying on outdated systems often face three critical limitations that directly impact their ability to stay competitive.
Scalability Constraints
Legacy systems require additional staffing to keep up with growing claims volumes. A system that processes 100 claims per day with acceptable efficiency becomes exponentially more complex when handling 1,000 claims daily. This often leads to increased error rates, higher compliance risks, and rising operational costs.
According to recent industry research, 38% of healthcare leaders report that more than 10% of their claims are denied, resulting in rework, administrative burdens, and delays in reimbursement.1 This not only impacts provider satisfaction but also contributes to increased financial strain and dissatisfaction across the entire healthcare network.
Regulatory Compliance Complexity
Healthcare regulations are evolving at a rapid pace. Requirements from CMS, state-specific mandates, and HIPAA considerations does create a regulatory landscape that demands constant updates. With manual processes, this often results in costly retraining, procedure updates, and continuous monitoring to stay compliant.
PwC forecasts that medical costs will rise by 8% annually in the Group market and 7.5% in the Individual market by 2025, driven by factors like inflation, higher prescription drug costs, and increased demand for behavioral health services. These pressures add complexity to claims processing and force health plans to adapt quickly to keep up.2
Provider Relationship Strain
Delayed claims processing impacts provider satisfaction and retention. Healthcare providers expect timely reimbursements and clear communication. Unfortunately, legacy systems often fall short, leading to administrative burdens and strained provider relationships.
Read our blog post on How Claims Adjudication Reduces Healthcare Claims Delays, where we explore key solutions to improve efficiency and reduce delays.
Understanding Modern Claims Adjudication Software Infrastructure
To fully appreciate the benefits of modern claims adjudication software, it’s important to understand how it tackles the challenges that legacy systems create.
1. Intelligent Processing Capabilities
Modern claims adjudication software uses machine learning to continuously improve its accuracy. This means that the system can "learn" from past claims, identifying patterns and reducing human error. Instead of manually reviewing each claim, the software can quickly analyze and make decisions, allowing health plans to handle a much higher volume of claims in a fraction of the time.
2. Integrated Compliance Management
Healthcare regulations change frequently. New rules, amendments, and compliance requirements can emerge almost overnight. Modern software takes the burden off your team by automatically updating to stay compliant with these changes. Whether it’s CMS guidelines or state-specific mandates, the system ensures that every claim follows the latest regulations, minimizing the risk of costly errors and audits.
3. Seamless Integration with Existing Systems
One of the greatest advantages of modern claims adjudication software is its ability to integrate with your existing infrastructure, such as Electronic Health Records (EHR) and billing systems. This eliminates the need for complicated, expensive customizations. These systems can “talk” to each other, sharing necessary data and creating a smooth, uninterrupted workflow. With seamless integration, your team won’t waste time on manual data entry or chasing down information from separate platforms.
For a deeper look at how modern systems can streamline your claims processing, explore Mirra's insights on optimizing healthcare operations or discover our innovative Medicare Advantage solutions that align with your needs.
Quantifiable Business Impact and ROI
Organizations that have adopted modern claims adjudication solutions report significant improvements in key operational areas, such as:
1. Processing Efficiency Improvements
Health plans typically experience a 60-80% increase in processing speed after transitioning to automated systems, enabling faster claim resolutions and reducing the time spent on manual processing. For example, one health plan saw a dramatic reduction in claims processing time from 14 days to just 3 days by leveraging automated claims adjudication software with high auto-adjudication rates and built-in quality checks. This not only improved accuracy by 23% but also reduced administrative costs by 35%.
2. Cost Reduction Metrics
Administrative costs typically decrease by 30-40% after implementing modern claims adjudication platforms. These savings stem from reduced manual labor, fewer errors, and improved operational efficiency. Automated systems enable organizations to manage 2-3 times their claims volume without increasing staff, contributing to substantial cost reduction.
3. Auto-Adjudication Rate Enhancement
Modern platforms, including those designed for integration with existing healthcare infrastructure, typically achieve auto-adjudication rates of 70-85%, compared to 30-45% with legacy systems. This boost allows claims teams to focus on more complex cases, freeing them from routine tasks. High auto-adjudication rates are complemented by editing software that ensures compliance and helps prevent fraud, waste, and abuse.
Why Mirra’s Claims Adjudication Solutions Are the Optimal Choice for Health Plans
Selecting the right claims adjudication platform requires careful evaluation of the capabilities that align with organizational needs and growth goals. Mirra’s Claims Adjudication solutions offer key features and benefits that meet these critical criteria, making it an ideal choice for health plans looking to optimize their claims processing.
Key factors to consider when evaluating a platform include:
Configuration Flexibility
Platforms should offer flexible configuration options that don’t require custom development. Business rules should be easily modifiable, allowing internal teams to adapt quickly to changing needs without relying on external vendors.
Mirra’s claims adjudication solutions, such as ClaimsLite and ClaiMaster, are designed with this flexibility in mind, enabling health plans to customize configurations according to their specific requirements without the need for complex development work.
Processing Transparency
Systems must provide clear visibility into processing logic and decision-making criteria. This transparency not only supports compliance but also builds trust with healthcare providers by enabling clear explanations of claims decisions.
Mirra’s platform ensures transparency through detailed dashboards and reporting tools that allow healthcare providers to track the progress and status of claims at every step, facilitating trust and smooth communication.
Implementation Methodology
The ideal platform should offer a phased implementation approach that minimizes disruption while delivering immediate value.
Mirra Healthcare offers a phased rollout for claims processing automation, allowing health plans to integrate gradually and start seeing the benefits quickly while maintaining operational continuity.
Ongoing Support Structure
Since claims processing is critical to health plans, the platform provider should offer robust support to ensure continuous operation and quick resolution of any issues that arise.
Mirra provides comprehensive ongoing support, ensuring that health plans have access to expert assistance whenever they need it, helping them optimize their claims processing at all stages.
Evaluating the ROI of Modern Claims Adjudication Software
When evaluating the potential return on investment (ROI) for implementing modern claims adjudication software, health plans should look at several key areas that directly impact both short-term efficiency and long-term profitability. Here are the main factors to consider:
1. Direct Cost Savings
The most immediate impact of adopting automated claims adjudication is the reduction in administrative costs. Modern systems significantly reduce the need for manual labor by automating repetitive tasks like claim data entry, validation, and processing. Health plans report a 30-50% decrease in costs per claim due to this automation, helping to recoup investment costs more quickly.
2. Increased Efficiency and Speed
Automated claims systems also enhance processing speed. Health plans that have transitioned to modern systems typically see a 60-80% increase in processing speed. With faster claim resolutions, providers are reimbursed more quickly, reducing friction and improving relationships. This increased efficiency directly translates into a better bottom line as fewer resources are spent on manual processing, and claims are resolved faster.
3. Reducing Risk and Improving Compliance
Another significant ROI benefit is risk reduction. Modern claims adjudication software comes with built-in tools that ensure compliance with ever-changing healthcare regulations. This reduces the likelihood of errors, audits, or fines. By automating compliance checks, organizations can avoid costly mistakes and improve the overall accuracy of their claims processing.
Why Mirra's Claims Adjudication Software Leads the Way
Mirra’s Claims Adjudication Software is designed with scalability, flexibility, and ease of use in mind. With features such as intelligent processing, integrated compliance management, and seamless system integration, Mirra’s solution provides an ideal platform for health plans looking to modernize and optimize their claims processing.
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Flexible Configuration: Mirra’s platform allows for easy customization of business rules, helping teams adapt quickly to changing needs without the need for expensive custom development.
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Transparency: Mirra ensures full visibility into the claims adjudication process, providing clear insights into decision-making logic and improving trust with providers.
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Ongoing Support: Mirra offers comprehensive support during implementation and beyond, ensuring a smooth transition and continuous optimization.
For health plans ready to take their claims adjudication to the next level, Mirra’s solution offers unmatched performance, flexibility, and reliability.
Conclusion
Health plans that modernize their claims processing operations are positioning themselves for long-term success in an increasingly competitive healthcare market.
For health plans ready to take the next step, Mirra's Claims Adjudication Solutions can streamline operations, improve accuracy, and ensure compliance. Our team is here to guide you through the process and develop a tailored strategy to meet your needs.
Contact us today for a no-obligation demo.
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