Benefits of Claims Processing Software for Payors & TPAs Explained

In the insurance and healthcare industries, claims processing involves handling requests when an individual needs medical care or treatment, with claims being processed and approved for payment by the entity responsible for such costs. The insurance companies that pay these claims are known as payors, and TPAs provide claims support or act on behalf of payors.

In the past, a single person or desk handled all claims processing, which could be time-consuming, prone to mistakes, and result in inadvertent violations of processing regulations. To address these challenges, payors and TPAs must turn to claims processing software, which automates and streamlines these tasks.

In this blog, we will discuss the benefits that every payor and TPA can gain by using claims software.

Claims Processing Software

1. Automation Improves Efficiency

The major advantage of using claims handling software is automation. Human error is common in mentally taxing manual jobs that need manual data entry and emailing, such as document collection, processing claims, or following up with plan members and providers. These tasks will be performed automatically and at a faster pace and with higher accuracy.

As an example, rather than having to email, call, or text a plan participant for a document for an Explanation of Benefits (EOB), the claims processing software connects with the carrier portal, retrieves the document, obtains the benefits details, and proceeds with the process. This saves hours of manual intervention and eliminates the need for back-and-forth communication.

At the end of the day, Automation is just a benefit to an internal team as well. Staff could hand off the simple, repetitive, non-urgent work, devoting time to more challenging cases that require a human touch, and even improve customer service on the whole. Ultimately, everyone wins: the staff who are PAs and the plan participants!

2. Flexibility Made Easy with Low-Code Platforms 

Each client has unique needs, including different rules, coverage types, reporting formats, etc. Before making a change to a workflow the involvement of the IT team and software developers was required. With low-code and no-code claims systems, the business team can now make the changes themselves.

If you want to change a form, edit a rule, or create a new intake process, it is now as easy as a few clicks. This increases the agility of TPAs because they can respond to changes in regulations, client requests, or internal preferences without being hindered by technical logistics. 

3. Speeding Up Claims to Benefit Everyone

Modern life works at breakneck speed; nobody likes to wait. As technology grows day by day, our patience is becoming shorter. Technology is now enabling businesses to provide services in mere minutes, which has spoiled customers and shortened their patience. We are also seeing it in plan participants, who also want their claims processed quickly. 

Employers want claims to be processed and need updates and reports onsite. TPAs want to get paid quickly for their work. Claims processing software systems assist with many steps of the claims process quickly. With full automation, an initial claim is reported, reviewed, and then either routed to an adjuster or reviewer, settled, or resolved in vastly less time than before. Data is captured and written at the point of entry, in real-time.

Everyone - teams, employers, and participants - can immediately get direct or real-time data, and not have to dig through stacks of paperwork or wait for a file. The speed of processing claims not only expedites reimbursements but also allows TPAs to keep their competitive edge and brand equity by operating quickly for their clients.

4. Transparent Reporting Strengthens Client Trust 

Customers prefer that claims are processed; they want to know that the TPA is doing a fair job. Claims handling software is where TPAs can show their effectiveness. Clients can see real-time dashboards, custom KPIs, and scheduled reports to have a clear understanding of their progress.

Transparency creates trust. Clients understand what is happening, where the money is going, and how issues are being resolved. Similarly, the openness allows TPAs to identify trends and develop their processes moving forward. 

5.  Easily Manage Multiple Clients in One System 

Generally, third-party administrators will work with various clients who all have differing workflows. Claims processing software currently available allows for multi-client entry where TPAs can manage all the clients in the same prompt, without confusing the data and settings set up for each. 

Reporting, user access, and rules by clients can be implemented. The TPAs can also maintain centralized control. This type of arrangement maximizes efficiencies and propels TPAs in both service levels and ultimately scales the work they do, without losing some of the intricacies that can and may come with each client once a new articulation is initiated.

Conclusion

Claims processing software is advantageous for third-party administrators (TPAs) and payors because it enhances workflows, reduces mistakes, and boosts transparency. The automation of work, combined with real-time reporting and multi-client management, creates a more efficient claims processing method that enables faster, more accurate claims processing. 

Investing in this technology not only increases efficiency and allows an environment of trust with clients, but also enables both TPAs and payors to remain competitive in the current rapidly evolving healthcare delivery system and insurance underwriting environment.