Third-party administrator Health Cost Solutions (HCS) has migrated from its traditional claims editing platform to a hosted service.
The benefits HCS is accruing illustrates why the claims editing market is moving toward a software-as-a-service model, said Gary Twigg, president and CEO of Bloodhound Technologies, which provided the platform for HCS for the last two years and now provides the SaaS model.
With clinical coding standards coming out of authoritative sources such as the American Medical Association, thus making content ubiquitous, editing vendors are competing on technology, he said.
“It’s how you deliver content, how you wrap services around the content,” Twigg said.
Customization, delivering sub-second response time and using business intelligence to capture data and deliver actionable reports for better business decision-making are key differentiators, he said.
“The return (on investment), the savings, is for our clients,” said Tawanda Travis, HCS’ vice president of IT. HCS’ clients gain data and business process transparency. For example, explanations of benefits have space limitations that often don’t tell why a claim wasn’t paid. Bloodhound Technologies’ service gives physicians an online view of all relevant data, Travis said.
With a SaaS model, HCS doesn’t have to worry about system limitations and back-end issues, she said.
Automating claims editing saves clients and their members time and money, and the reduction in manual intervention in turn reduces workload. HCS’ savings on claims that have been edited automatically runs between 14 percent and 16 percent, she said.
“TPAs compete with health insurance carriers, so service and client satisfaction go a long way,” Travis said.
“Software-as-a-service is still a new model that faces the same challenges as the ASP model – integration, management of the data and relationships, privacy and security, redundancy,” said Janice Young, program director at Health Industry Insights. “It’s important to realize that it still needs to be proven.”
Vendor execution is critical, she said. Caution aside, SaaS presents great opportunity, she said. “The promise of information transparency and automated processes coupled with real-time analytics delivered as software as a service can level the playing field for TPAs and small- to mid-size health plans,” Young said.
