Making the Shift to Pre-Payment of Itemized Bills

Mar 19, 2024

Estimated administrative costs in the U.S. healthcare system related to billing and insurance hit $496 billion in a 2019 report released by Centers for Medicare and Medicaid Services.

Central to this cost riddled with excess is the claims process between payer and provider, including claims submissions. Wherever there’s excess, there’s an opportunity to “trim the fat” so to speak. Due to technological advances in healthcare tech, we can now streamline processes that will shape the future of healthcare in the U.S.

Although it may be an intimidating thought at first, today’s top tech options are well worth the time and effort to integrate into company systems and workflows. The best-in-class solutions provide simple integrations that diminish the overall administrative burden for both provider and payer. Ultimately, these solutions namely itemized bill review, allow us to do more work with less manpower while increasing efficiency and lowering costs.

The challenges of our healthcare system are only apparent in the claims process of itemized bill reviews (IBR), where payers and providers have long been strapped with an antiquated system of sharing important medical information via fax, online portals, and mail.

Both sides understand the monumental task of managing a system that sees millions of new claims submitted daily. Outsourcing the management of the IBR process for both payer and provider has become the industry standard. While outsourcing has been a lifesaver, it’s also a costly endeavor lacking efficiency and needed feedback.

Technology is rapidly evolving, and times are changing. It’s important to understand the options and how to make the best decisions for your company’s itemized bill review process.

What you need to know about Itemized Bill Review:

  • It’s time to start Making the Shift to Pre-Payment of Itemized Bills. A massive productivity lift allows payers to insource their IBR process by leveraging technology, all while reducing inefficiencies, diminishing provider abrasion, and saving money.

The jump from fax, online portals, and mail to an automated IB review solution can feel like a huge undertaking with a massive learning curve, but don’t let what you don’t know scare you. The name of the game is to make it easier for both payers and providers to exchange the information needed so that claims can be settled as quickly as possible.

  • Once you understand the possibilities, integrating the right workflow and technology solution is not as difficult as you might think.

Post-payment recovery and outsourcing will likely always be a part of the process and healthcare system, especially when dealing with larger IBs. The current system is slow and cumbersome, requiring teams of people to painstakingly review IBs, line-by-line.

The present future of pre-payment itemized bill review is here, and it’s an amazing opportunity to revolutionize the healthcare system. By leveraging technology to insource IB reviews, more work can be done faster with fewer people, along with higher efficiency and speed, all while diminishing provider abrasion and lowering costs.

Our CAVO® platform with our CAVO IB Predict overlay allows health plans to audit IBs at least 5x faster than a manual audit. As discussed above, with the shorter outpatient IBs, CAVO® intakes and extracts the data from medical records, itemized bills, and other clinical information. With CAVO® IB Predict, an insourced team can quickly review IBs, and recommend prioritization of denied charges – along with detailed reasons for flagged charges. This process alone minimizes the immediate risk of excessive outlier payments, as well as minimizing the risk of loss from payouts that aren’t recouped before the window of post-pay audits closes.