Automated claim and payment verification

Abstract

Since the start of managed care, there has been steady deterioration in the ability of physicians, hospitals, payors, and patients to understand reimbursement and the contracts and payment policies that drive it. This lack of transparency has generated administrative costs, confusion, and mistrust. It is therefore essential that physicians, hospitals, and payors have rapid access to accurate information on contractual payment terms. This article summarizes problems with contract-based reimbursement and needed responses by medical practices. It describes an innovative, Internet-based claims and payment verification service, Phynance, which automatically verifies the accuracy of all claims and payments by payor, contract and line item. This service enables practices to know and apply the one, true, contractually obligated allowable. The article details implementation costs and processes and anticipated return on investment. The resulting transparency improves business processes throughout health care, increasing efficiency and lowering costs for physicians, hospitals, payors, employers--and patients.