7 minute read
Why Claims Integration Is A Crucial Part of Any Supplemental Health Benefit Strategy
By Randy Finn
Making claims integration work for members
Among the most coveted benefits that employers are offering to attract and retain top talent are supplemental health plans like critical illness, accident, and hospital indemnity. Yet many employees struggle with understanding how to use their benefits and the challenges with the claims-filing process.
This is where claims integration can help. Claims integration can drive meaningful improvement to the member's claim experience when leveraging medical claim data. We have been deploying claims integration capabilities with medical claims for voluntary supplemental health benefits for over a decade, and our experience gives us a unique perspective not only about where claims integration has been, but also where it needs to go. Based on our experience, we have introduced a number of initiatives designed to modernize claims integration and improve claims incidence. These efforts have documented results showing that claims integration, when done correctly, can have a demonstrated impact on an organization’s supplemental health benefit strategy.
Under our Simplified Claims Experience we see 1.8x higher claims incidence & 1.24x higher claims payments for members with medical data compared to those without. [1] In this article we will share what we have learned from the past and how we see the future of claims integration. And we will show how plan sponsors can utilize new integration strategies to make their benefits packages more effective in attracting and retaining employees.
How Effective Claims Integration Solves The Problem
One of the best ways to address the issue is through claims integration. Integrating claims from a member’s employer-sponsored health plan with their supplemental health coverage holds the power to simplify the member’s claims-filing experience and improve the value of voluntary plans in the eyes of members.
So, what is claims integration and how does it work? In broad terms, claims integration means using “non-supplemental health plan” claims data for initiating and/or processing a supplemental health claim in place of, or in addition to, a member’s submitted paperwork.
While claims integration can be deployed with a variety of different data, using medical claims data is the most powerful and most impactful method. Utilizing claims integration capabilities with medical claims data drives higher utilization of claims.
Claims integration terminology and capabilities can vary significantly. It is important to understand in detail what aspects of claims reminders, submission processes and adjudication protocols are being implemented. With so many solutions being described as “claims integration,” simply deploying one of these tactics does not guarantee increased utilization of supplemental health plans. In short, different solutions lead to different claims utilization impacts.
For example, claims integration could involve communications sent to a voluntary member reminding them to submit their supplemental health claims based on an event. But this approach still requires significant action on the member’s part because in many cases they still have to upload medical documentation, which can present barriers to utilizing coverage.
Additionally, the data used to power a claims integration solution is extremely important. Medical data is best because it includes all clinical events, no matter how major or minor the service. Another important factor is determining for which individuals the solution has data. Is it all covered members, or just employees?
Where the data comes from can also influence the effectiveness of any claims integration solution. While data from a third party may be fairly inclusive, a claims integration solution that relies on data from a third-party source could exclude important data sources like physicians’ letters or other clinical notes.
Another important issue is how often the data is shared. A medical carrier accessing its own medical system has near-real-time access to medical data both pending medical claims and paid/denied medical claims. Using data from a third party not only can result in missing data, but it can also result in a lag in when the data is delivered. The longer the delay in getting the medical data, the less impactful that data is on the member’s experience.
For example, if there is a lag of one month from the date of a medical event to the date the data on the event becomes available, there could be significant consequences. A member could submit their supplemental health claim to their carrier after having visited the doctor but would still be required to provide all the paper documentation since the supplemental carrier would not yet have the medical claims data.
Collaborating To Put Benefits To Work
As a medical carrier, we have direct access to the exact benefits payable based upon our medical data, but it is also important to combine claims integration capabilities with other plan sponsor medical carriers to enhance the experience of all employees, not just those on the medical plan. This is an important element in the ability to collect the medical data, which allows carriers to adjudicate claims based on the precise benefits utilized by members.
Just as importantly, we also work with plan sponsors to get the most out of all the benefits they provide. We want employees to maximize their utilization of benefits, because employees who do not use their benefits often do not value them.
And benefits that are not valued by workers are less likely to help attract and retain talent. That’s why claims integration is a critical part of any modern benefits strategy.
A Glossary of Key Terms
Terminology and capabilities regarding claims integration can vary significantly in the market. It is important to understand in detail what aspects of claims integration, submission process and adjudication protocols are being implemented. The following glossary defines and provides crucial details about some important terms.
Claims Integration
Using medical, disability or life insurance claim data (aka non-supplemental health data) for initiating and/or processing of a supplemental health claim in place of or in addition to a member’s submitted paperwork.
Medical: Employee and/or dependent data resulting from any medical treatment or service.
Disability: Employee-only data resulting from a qualified short-term or long-term disability event.
Life Insurance: Employee and/or dependent data resulting from a death or accidental dismemberment.
Claims Submission Approaches
The carrier’s method for how claims can be submitted.
Online/Paper Claims Submission: Member-initiated supplemental health claims with all supporting medical documentation provided to the carrier.
Simplified or “Integrated” Claims Submission: Member-initiated supplemental health claims without having to upload any supporting medical documentation.
Auto-Claims Submission: Carrier-initiated supplemental health claims based on review of medical claims data. Member takes no action to initiate the claim.
Claims Adjudication Protocols
Carrier’s internal protocols used to process and pay claims in their system.
Manual-Adjudication / Semi-Automatic Adjudication: Member’s claim is manually entered by a claims processor into the carrier claims system and payable benefits are "selected" using medical codes and/or uploaded documentation. The claims adjudicator is making decisions on payable benefits. On completion by the claims processor, the carrier’s system processes and makes payments to the member without further claims processor interaction.
Auto-Adjudication (100% system driven): Member’s claim is processed without any human claims processor involvement. Claim review and processing occurs in the carrier’s claims system by utilizing medical codes (ie, IC10, rev codes, procedure codes, CPT codes) to make payment.
NOTE: The term Auto-Adjudication is often used in the market incorrectly to convey a carrier’s Claims Submission Approach. Claims Adjudication protocols are very different from Claims Submission Approaches. The term Auto Adjudication should only be used to refer to the carrier’s internal claims processing approach, not how a member's claims get submitted.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Information is believed to be accurate as of the production date; however, it is subject to change For more information about Aetna plans, refer to Aetna.com.
Randy Finn, Executive Director, Aetna - responsible for all business operations for Aetna’s Voluntary segment, which includes product development and claims integration solutions, pricing, underwriting, enrollment communications and strategy, billing, eligibility management and plan sponsor services. In 2014, he joined Aetna to build out their voluntary supplemental benefits portfolio (Accident, Critical Illness, and Hospital Indemnity), value proposition and capabilities.
