At this week's annual HLTH conference in Las Vegas, UnitedHealth Group's data analytics subsidiary Optum announced the launch of Optum Real, a real-time claims management system designed to eliminate friction for providers and payers in submitting claims in a timely manner and receiving reimbursement.
This announcement is not premature, given that provider dissatisfaction with insurance companies' “delay and denial” policies has reached a boiling point. The company's executives took the stage at HLTH to explain how the vast majority of claims are processed quickly and only a few are a headache. The reason: lack of transparency.
“If I had to sum it up in one word, I would say the biggest challenge in claims and reimbursement is guesswork,” Puneet Maheshwari, senior vice president and general manager at Optum Real, told an audience Tuesday. “The guesswork that happens on the provider side. The guesswork that happens on the payer side creates a lot of work and overhead for all parties involved…”
Enter Optum Real.
Optum Real is a “multi-payment platform,” according to a press release from the Minnesota company [that] Allows real-time data exchange between payers and providers, enabling the identification and interception of known issues when claims are submitted. “Given the promise of “instant clarity” in the system developed by Optum, it's no surprise that UnitedHealthcare, a sister company of UHG, is the first health plan in the United States to adopt the technology.
In an interview following the onstage panel, Maheshwari claimed that Optum Real is designed to eliminate data fragmentation that hinders the claims adjustment process and could save millions of dollars that providers pay to clinical documentation improvement teams to increase their chances of receiving reimbursement, and millions of dollars that payers pay to claims aggregation companies to ensure that providers are acting in compliance. What follows is a lightly edited Q&A from the discussion.
Medical City News: You call it real-time, but nothing in healthcare is actually real-time, right? This is not the same as seeing your Uber Eats meal delivered to your car in real time. Healthcare uses this term loosely, correct me if I'm wrong, but what does real time actually mean?
Maheshwari: Yes. So I would say, this observation is very astute. Our desire is to make it real-time, truly real-time.
Let's take a look at today's process for a simple dynamic example. At the end of a day or two after meeting with the provider, the provider completes the documentation, but by then the information has been lost. It is then sent to the Clinical Documentation Improvement Team (CDI) in batch mode. If incomplete, it will be returned to the provider for completion. Then, in batch mode, it's sent to the coding team, and if they find bugs, they make changes upstream and change those bugs. Then, in batch mode, it goes to the claims team to clean up the claims based on payer-specific rules. They then send it in batch mode to the clearing house, which runs a set of checks and sends them to the payers who signed the set of checks. Happy situation. Everything goes smoothly and takes two to three weeks.
If the situation is bad, it may take several months. In this case, something is returned because of an administrative error or because the payer doesn't have enough information to approve something right away. Then the back and forth begins, which may require going from the same loop to more loops. This is the current state, and the reason for the current state is a lack of transparency between payers and providers. They try to do this by guessing.
Real-time transparency takes the guesswork out of it. The real transformation comes when you can ask these real-time queries while caring, and when you are able to make the right decisions, that's what really matters.
For example, a patient is coming in for an MRI. Do they cover this? This requires the provider to ask questions of the payer. It then requires payers to understand what benefits are available, what the contract with a particular provider is, what the guidelines are for approving or disapproving an MRI and then making a referral, and making it clear how much the provider will be paid and what the patient's responsibilities will be. We achieved this functionality before the advent of services through Optum Real.
There is not much variability in brain MRI with or without contrast agent. But someone walks in because they've got a cut on their hand – you don't know what's going to happen on the exam. They may receive stitches. Then they may give a tetanus shot. They may get extra support because they have diabetes and it is not easily cured. So the complexity of the case can be very different depending on who gets the cut, not just this one. Whether it's a three centimeter cut or a five centimeter cut changes how it's encoded in the encounter. Therefore, this variability can be accounted for by today's features, where environment marking capabilities can paint encounters in real time.
Now, if that happens, we can introduce and we are introducing the ability to evaluate whether a document is complete and accurate. Example of three centimeters and five centimeters. Right there, you can say… “Hey, you forgot the length of the suture type, can you give me the length of the incision?” Once the documentation is complete, I can code it myself. I can fill it out myself and get a real-time response from the payer on whether this claim or claim inquiry is approved. We can answer, “How much responsibility will the patient have” and “How much will the provider get paid”. All of this is complete and ready to go before the patient leaves the exam room, making the three-week process we discussed collapse to the checkpoint.
Medical City News: So that seems very optimistic to me because everything in healthcare is so slow. As far as I know, providers are using ambient technologies, and some ambient technologies have logging and encoding capabilities. So providers can create perfect notes. I understand all of this, but I'm still not sure the provider is capable of fully understanding your needs unless you explicitly share with them your agreement that “well, this will get paid and this won't.”
Maheshwari: This is exactly what makes this solution different from others. Today, everyone looking at reimbursement solutions and AI is asking, “Can I build a better AI for providers?” And then the other side says, “I can build a better AI for payers” so that they can compete with the provider's AI, right? As a result, what used to be a competition between rule-based systems is turning into a competition for artificial intelligence. We will end up in the same place again.
The solution to this problem is to create real-time transparency. You're right, payers have historically been cautious (for lack of good words) about creating full transparency, but what we're trying to do is… Unitedhealthcare has opened up these APIs that will provide real-time transparency for these queries from payers with a very high level of precision, not just to say “Puneet is eligible for this thing,” but to a level of specificity that is, “Puneet is eligible for this thing for this specific set of circumstances.” Puneet's diagnosis code is used in the benefit structure of my contract with his specific provider. “This decision has been missing in the past.
Medical City News: The business model of insurance is very simple, right? You are a for-profit entity and the way you make money is that you pay out fewer claims than you bring in premiums. Now, if you create a transparent system to provide protocols, you are threatening your own business model to some extent. do not you?
Maheshwari: So if you look at the statistics, the numbers tell a different story. When providers submit claims, 80 percent are approved and paid. About 10% to 20% require rework. Most rework occurs because the payer does not have enough information to pay the claim…and the provider has some degree of problem or error in the claim. [Note here that Maheshwari seems to imply that all errors/problems or lack of information in the claim lie necessarily on the provider side. I personally have been in situations where I fought my insurance company after they provided incorrect provider network information to me. I won only partial reimbursed from the payer even though the fault for providing wrong information lay completely with the payer. The payer in that case was not Unitedhealthcare, however.]
The final denial rate due to medical necessity is in the low single digits. As a result, Optum Real completely eliminates all overhead associated with first-time returns between payer and provider. Now, I as the payer and you as the provider can still argue whether this is medically necessary. But the denial rate is 2% to 3%. The rest is administrative expenses.
But you can go one step further. Even if 80% of charges are reimbursed within 2 weeks, there is a $250 billion RCM industry on the provider side and about $100 billion on the payer side for payment integrity. As a result, the industry spent $300 billion to $350 billion so that providers could be compensated for their services on claims that fell into the approved 80% category. Now, if we create this real-time transparent system, you will gain significant efficiencies.
Medical City News: So is Optum Real trying to put these RCMs and the payments integrity industry out of business?
Maheshwari: I would say shutting down is probably a more ambitious and aggressive statement. I would definitely say that we have a responsibility as patients, payers and providers to eliminate the administrative waste and administrative barriers that we have.
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Does this mean the days of delay and denial are officially over for insurance companies? Allina Health, a health system based in Minnesota, where UHG is also headquartered, apparently saw significant cost savings through Optum Real, according to a press release from Optum.
As for providers in other parts of the country, only time will tell. We ask providers to contact us if Optum Real has materially improved your experience with the Unitedhealthcare claims and reimbursement system. In the meantime, we at MedCity News will keep it real.
