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How Affordable Care Act Has Changed the Healthcare Insurance Market


Affordable Care ActExperienced claims processing outsourcing companies have braced themselves for the Affordable Care Act (ACA) to help healthcare insurance providers cope with the ever changing claims processing requirements. Concerns are raised that the conventional legacy claims processing systems would end up being inefficient. Industry experts and these healthcare payers have come to realize that focusing on automation as before might not work out well.

Automation Not Considered the Right Solution Any More

The Affordable Care Act (ACA) has raised questions regarding automation of various business processes for healthcare payers. Automated applications for claims processing are getting more and more expensive for insurance providers to maintain. Moreover, they also need to be upgraded continually though on paper they are supposed to improve efficiency for the insurance companies.

Healthcare insurance providers are therefore reconsidering their automation and custom applications strategy. A lower level of application customization and automation and increased investment in personnel training and process optimization is considered to be more cost-effective and flexible though all these measures sound like heavy resource sappers.

The reason for this is that the ACA’s measures have made the healthcare insurance sector more dynamic, which means that the players in this market have had to keep adapting themselves to face the demands of the market. The established approach has been considered not to be as well-equipped to meet the needs.

Insurance providers had invested significantly into the development of various applications for the automation of the claims review and processing tasks, with nearly 90% adjudication achieved. The existing applications were merely upgraded according to regulatory changes. But now, with new ACA measures, regulations keep changing rapidly and upgrading has to be done more frequently.

Reducing Overall Claims Processing Costs a Priority

A solution would be not to focus much on over-customization of technology. Insurance payers must rather focus on reducing the overall costs in processing a claim. Auto adjudication rates should be limited to 70%. This technique would bring down the complexity which would make it easier to upgrade or replace the legacy systems without much disruption, improving agility and flexibility. Of course this would require hiring and training more personnel, but overall the entire process would become more cost effective.

Thanks to hectic activity in terms of mergers and acquisitions, many healthcare insurers have begun maintaining multiple processes for the reviewing and closure of a reimbursement claim. The sudden changes in the regulation on account of the ACA have made the situation even more volatile. More than looking to reduce costs in individual processes rather than the overall process, the need of the hour is to standardize the claims processing process rather than having to customize in each and every situation.

Claims processing outsourcing companies can actually devise new systems to cope with the dynamic situation presented by the Affordable Care Act. Experienced companies can offer systems that do not require extensive modifications according to the changing conditions brought about by this regulation. Outsourcing of claims processing would be the ideal option if the outsourcing partner is adaptive and technologically proficient. With cloud-based solutions available, partnering with the right provider can help healthcare payers even in this challenging environment.

About Rajeev R

Rajeev R

Manages the day-to-day operations of MOS from NY. With an interest in information technology, Rajeev has guided MOS to extensive use of digital technology and the internet that benefits MOS as well as MOS clients.