Optum Launches Real-Time Claims Management System at HLTH 2023

At the annual HLTH conference in Las Vegas this week, Optum, a subsidiary of UnitedHealth Group, unveiled Optum Real, a new real-time claims management system. This innovative platform aims to streamline the claims submission and reimbursement process, addressing longstanding frustrations between healthcare providers and insurers. The launch comes as provider dissatisfaction with insurers’ so-called “delay and deny” practices has reached a critical point.

Executives from Optum took the stage to highlight how the majority of claims are processed efficiently, with only a small fraction causing significant headaches. According to Puneet Maheshwari, senior vice president and general manager of Optum Real, the primary issue lies in a lack of transparency. “If I have to summarize it in one word, I would say the biggest challenge in claims and reimbursement is guesswork,” Maheshwari stated during the presentation.

Transforming Claims Processing

Optum Real is described as a “multi-payer platform” that facilitates real-time data exchange between payers and providers. This system enables the identification of issues at the moment of claim submission, thereby reducing administrative burdens. Maheshwari emphasized that the platform aims to eliminate data fragmentation, which often complicates the claims adjustment process.

In an interview following the panel discussion, Maheshwari elaborated on the current claims process. Often, documentation is completed days after a patient’s visit, leading to delays. Claims are then sent in batches to various teams for review, which can take weeks or even months. “What real-time transparency enables is that it removes the guesswork,” he explained. “Real transformation comes when you can ask these real-time queries in the moment of care that really matters.”

For example, when a patient arrives for an MRI, the provider can immediately check coverage and understand the specifics of reimbursement, significantly reducing the time required for claims to be processed. Maheshwari noted that this system promises to provide clarity regarding patient liability and provider payments before the patient leaves the examination room.

Addressing Industry Challenges

Despite the optimistic outlook, questions remain about the feasibility of achieving real-time processing in an industry often characterized by delays. Maheshwari acknowledged that while the aspiration for real-time claims processing is ambitious, it is essential for improving efficiency. He pointed out that while 80% of claims are initially approved, the remaining 20% often require reworking due to lack of information or errors, resulting in unnecessary costs for both providers and payers.

According to Maheshwari, the healthcare industry currently spends approximately $300 billion to $350 billion annually on revenue cycle management and payment integrity. He asserted that Optum Real could dramatically reduce these costs by enhancing transparency and efficiency in the claims process.

While the potential benefits of Optum Real are significant, Maheshwari faced questions about the implications for the traditional insurance business model. Critics argue that increasing transparency could threaten profitability by requiring insurers to pay out more claims. Maheshwari countered this concern with statistics indicating that the final denial rate for medical necessity is in the low single digits, suggesting that much of the administrative overhead stems from inefficiencies rather than a refusal to pay valid claims.

As healthcare systems across the country contemplate the implications of this new technology, it remains to be seen how effectively Optum Real will address the longstanding issues of claims processing. Allina Health, a Minnesota-based health system, has already reported significant savings attributed to the system. Providers nationwide will be closely monitoring their experiences with UnitedHealthcare’s claims and reimbursement processes as Optum Real rolls out.

As the healthcare industry moves forward, the success of Optum Real may redefine the dynamics between providers and payers, potentially marking the end of the “delay and deny” era in insurance practices.