By Calvin Glenn-Oracle on Dec 01, 2015
With the steady increase of healthcare costs, health insurance payers are challenged to find new ways to reduce cost. As a payer, you have three ways to achieve this: reduce reimbursement, reduce coverage or reduce the cost of running your business. The first two options shift the cost towards providers and members and are not viable in a competitive marketplace, making the third option – reducing the medical loss ratio – an attractive choice.
Kathy McCarthy, Director of Sales Consulting for Oracle Health Insurance, discusses the topic in today's post.
Any payer strives towards a claims administration where straight-through-processing is the norm. Yet, not many payers get to boast auto-adjudication rates higher than 95%. In fact, many payers do not even come close. And given the volume of claims in health insurance, even if you achieve an auto-adjudication rate as high as 95%, that still means you have to deal with (tens of) thousands of claims that can’t be processed without some kind of intervention.
Obstacles to getting here include:
- Inherent Complexity
- Collaboration, Mergers and Legacy Systems
- Evolving Benefit Plans
One alternative is to make sure that your back office is flexible and agile enough to follow the business wherever it may go. After all, isn’t the purpose of enterprise software to make business easier? There are three aspects to straight-through-processing in a componentized architecture:
- Auto Adjudication
The combination of these traits is the primary design principle of Oracle Health Insurance Components. They offer pre-integrated applications for the health insurance market that are configurable through fit-for-purpose, parameter-driven rules – giving you the agility you need to keep up with the constant influx of new market requirements – that can be extended with your own settings and logic to meet your specific business requirements – giving you the flexibility you require to achieve operational excellence.
For more information on Oracle Health Insurance Components, please visit oracle.com/insurance.
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