Real-Time Claims Adjudication: The Secret for the Doctor Getting Paid on Time

Here’s how real-time claims adjudication – or instant payment of claims for doctors -works.

The doctor has an EHR. A data entry clerk in the office enters the claim data. The claim is submitted through the EHR.

And Presto! The doctor is paid.

By the time the patient reaches the check-out desk, the doctor has received a payment commitment from the insurer, just as Visa and Mastercard does after a customer swipes a card.

Unfortunately, it doesn’t work that way in most doctors’ offices.

In the first place, they don’t have an EHR.

Secondly, they don’t have a data entry clerk. Thirdly, they or their staff don’t have time to wade through 4500 diagnostic codes and 1500 procedure codes to find just the right codes for appropriate reimbursement.

If you’re a generalist, with a high volume of patients with a myriad of conditions, finding the right code can be a nightmare. So the office may take a few days before submitting a claim.

The key to instant payment is an EHR, says the Obama administration. Furthermore, install these electronic records, and we will reward you with a 2% bonus for being good boys and girls electronically, and for saving “The system” up to $250 billion to $350 billion in administrative costs.

Of course, there are catches. You may save "the system," but it costs doctors. They must meet certain conditions, convert from paper to electronic records, use EHRs only for “meaningful use,” pay high fees for installation and maintenance, disrupt their usual routines and cut back on their productivity by up to 30% over the first year while adapting electronically. Never mind. It's all for government good.

Nevertheless, instant processing of claims is an attractive concept. For one thing, all the data is submitted upfront, and insurers do not have to come back for further documentation. Meanwhile, until the documentation is done, doctors will just have to wait to get paid.