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Adjudicación de reclamaciones en tiempo real
In 2006, Humana rolled out the RTCA process that allows claims to be adjudicated instantly through a practice's practice-management system (PMS). Practices can immediately provide Humana-insured patients with the final amount due at the time of their visit and then collect payment by cash, check, credit card or health savings account (HSA) reimbursement card. "Humana is the first health plan capable of integrating the provider's desktop with our adjudication system," said Janna Meek, director, integrated provider solutions in Humana's provider network operations group. "This is about cash flow for providers. With high-deductible health plans (HDHPs), providers take on more financial risk for collecting. We believe that RTCA will help alleviate any cash flow issues practices may be experiencing as a result of members buying HDHPs." To implement RTCA, a practice must have a PMS capable of communicating with Humana's system. In some instances, Humana can help practices prepare their PMS. In addition, practice staff must be able to institute procedural changes to make RTCA work. The benefits of implementing the solution are evident, according to Humana's original RTCA pilot site, which completed its first full year with the system in 2006 and now is the system's major user. The RTCA process has dramatically changed collections for MacGregor Medical Center in San Antonio, Texas. Terri Foose, MacGregor's chief financial officer, said, "Previously, we were getting paid for 80 percent of our claims in about 15 days; and within 30 to 45 days, we would get 95 percent of claims — and for the rest, we would have to deal with denials and so forth. With RTCA, we're collecting about 93 percent of Humana transactions at the door." Moreover, Foose explained, Humana is bringing more RTCA-eligible products to the market, creating an ever-increasing number of patients who can use the system. In addition, the practice sees significant savings from not having to send statements. "We figure it costs $6 to $8 on a very conservative basis to send statements — I've seen studies stating as high as $15 a statement," Foose said. "We don't even send statements for balances under $15 because of the cost." Of course, those low-balance statements are the easiest for MacGregor to collect at the time of service with RTCA. As a result of all the collections, Foose said that during 2006, MacGregor's first full year using RTCA, the practice's receipts increased by 17 percent. "We've accelerated our collections so that last year's income was equal to 13 months of collections previously, which made 2006 very profitable," Foose noted. "It wasn't easy in the beginning. The transition takes training and education for the people who work at the front desk," Foose added. "We had to realign some jobs because, previously, coding wasn't done in a real-time environment. Now, we're looking into getting our electronic medical records on board, which will be a much easier system. But with RTCA, we immediately complete the transaction, and we have our money within 36 hours. We're saving not just the cost of sending a statement, but we're avoiding the cost of a missed opportunity to get the money upfront."
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