During the annual HLTH conference in Las Vegas, Optum, the data analytics subsidiary of UnitedHealth Group, unveiled its new real-time claims management system, named Optum Real. This platform aims to streamline the claims process between healthcare providers and payers, addressing longstanding frustrations surrounding delays and lack of transparency. The announcement comes as provider dissatisfaction with insurance reimbursement practices has intensified, often described as a “delay and deny” approach.
At the conference, executives from Optum highlighted the efficiency of their new system. According to Puneet Maheshwari, senior vice president and general manager of Optum Real, the majority of claims are processed without issue, but a small percentage create significant challenges due to unclear communication. “If I have to summarize it in one word, I would say the biggest challenge in claims and reimbursement is guesswork,” Maheshwari noted.
Optum Real is designed as a multi-payer platform that facilitates real-time data exchange between payers and providers. This technology aims to identify and resolve issues at the point of claim submission, which could transform the reimbursement landscape. UnitedHealthcare, a sister company under the UnitedHealth Group umbrella, is the first health plan to adopt this innovative system.
Addressing the Challenges of Claims Processing
Maheshwari elaborated on the complexities of the current claims process, which can often take weeks or even months due to various administrative hurdles. A typical claim progresses through multiple stages: documentation completion, clinical review, coding, and finally submission to the payer. This lengthy process is rife with opportunities for errors and delays. “By the end of the day or two days after the encounter with the provider, the provider completes the documentation, but by then information is already lost,” he explained.
Optum Real aims to eliminate this inefficiency by enabling real-time queries at the moment of care. For example, if a patient arrives for an MRI, the system can instantly determine coverage and reimbursement details, allowing providers to obtain necessary approvals before the service is rendered. This capability could effectively collapse the traditional claims process timeline, significantly enhancing operational efficiency.
Moreover, Maheshwari emphasized that the platform’s transparency will foster better communication between payers and providers. “What real-time transparency enables is that it removes the guesswork,” he stated, highlighting the need for clarity in reimbursement protocols.
Potential Impacts on the Healthcare Industry
While the introduction of Optum Real is met with optimism, some industry observers express caution. The healthcare sector is known for its slow pace of change, and skepticism remains about whether this system can truly deliver on its promises. Maheshwari acknowledged these concerns, asserting that the aim is not to disrupt existing systems but to reduce administrative burdens for both payers and providers.
The healthcare reimbursement model has traditionally operated under a for-profit premise, wherein insurers seek to minimize payouts. This raises questions about whether a transparent claims system might threaten the status quo. Maheshwari pointed out that the statistics indicate a different narrative; approximately 80% of claims are approved and paid without issue, while only about 2% to 3% face denials due to medical necessity.
Despite the challenges, the potential savings are substantial. The revenue cycle management (RCM) industry on the provider side is valued at around $250 billion, with an additional $100 billion spent on payment integrity by payers. By creating a transparent and efficient claims process, Optum Real could significantly reduce these costs.
The early results from health systems like Allina Health in Minnesota, where Optum is headquartered, indicate positive outcomes from using Optum Real. As the system rolls out nationally, the real test will be whether it can enhance the claims experience for providers across the country.
As Optum Real sets out to redefine the claims management landscape, the healthcare industry will be closely watching its implementation and effects on reimbursement practices. Providers are encouraged to share their experiences as this initiative unfolds, and MedCity News will continue to monitor developments in this critical area of healthcare.
