Health Insurance Claims Adjudication

Claims Adjudication Occurs between a Healthcare Provider Submitting a Claim to a Health Insurance Company and the Insurance Company Making a Payment Back to the Provider.

Approximately 85% of Claims are Adjudicated by Computer Software without Any Human Review. This Process is Called Auto-Adjudication. If a Human Does Review the Claim, it Costs Approximately $20 Per Claim.

Most Health Insurance Companies also Set a Dollar Threshold of $10-$15,000 Per Claim Below Which Claims are Auto-Adjudicated.

Often the Software Used in Claims Adjudication is Very Old, such as the COBOL Software Language that was Created in 1959.

Claims Adjudication Software Does Not Catch All Doctor and Hospital Billing Fraud, Waste and Abuse. For Example, ProPublica Reported at $10,000+ COVID Test That Was Paid by an Insurance Company and Quest Diagnostics Was Able to Lower its Employee Health Plan Costs by Catching Billing Errors that their Own Insurance Carrier Missed.

Please forgive the spelling errors on the whiteboard.

Sources:
https://www.aetnabetterhealth.com/con...

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