• Home
  • Newsroom

Humana's New Real-Time Claims Adjudication Enables Faster Member Payment to Physicians and Calculates Member's Exact Portion of Bill


Tuesday, January 31, 2006 9:58 am EST



Public Company Information:

"The idea of real-time claims adjudication initiative is a step in the right direction"
LOUISVILLE, Ky.--(BUSINESS WIRE)--Jan. 31, 2006--

  Simplified Administrative Solution Enables a Fully Adjudicated Claim at Time of Service  

Humana Inc. (NYSE: HUM) today announced the launch of its integrated real-time claims adjudication process that will simplify administrative tasks and help physicians obtain payment for services from patients more quickly.

This solution comes as high-deductible health plans (HDHPs) continue to gain popularity with employers. Humana's real-time claims adjudication integrates a number of partners and technologies that submit claims and return the adjudicated claim by calculating the exact dollar amount of most health plan members' financial responsibility before the member leaves the doctor's office.

"This new capability is a much more realistic and efficient approach than any other options that are available to physicians today," said Bruce Perkins, Humana's senior vice president for national contracting. "It replaces other alternatives that involve time-consuming administrative office hassles, such as duplicative, manual keying of claims information, with one-time entry, followed by an instant swipe of a debit card."

Those other alternatives require the patient information to be manually keyed twice, first into a computer or card terminal - much like each grocery item's bar code would have to be keyed in -- then into the practice management system. That method is often time-consuming and can lead to errors in data entry.

Currently, physicians send claims to Humana either electronically or through the mail. The claims process has to be "adjudicated," which takes into account the specific member's benefits and health plan discounts. Once the claim is paid, doctors must then bill the member for the balance, resulting in delays of weeks or months before the physician gets final payment from the member.

"Until now, the problem doctors had with using real-time claim solutions has been the hassle factor," said Bruce J. Goodman, senior vice president and chief service and information officer. "No one wants to enter the same information twice and into two different systems. But, by using Availity and partnering with practice management and other vendors to form an integrated solution, Humana can deliver the information they need and without any added steps. We're using our advanced technology to simplify the use of high-deductible plans for members and removing worry about cash flow for their providers of care."

For most of its members who hold the HumanaAccess Visa debit card, Humana's real-time claims adjudication offers a more simplified administrative approach than available options today. Providers using one of the participating practice management solutions enter the claim once in the practice management system. The claim is submitted electronically to Availity, LLC, Humana's primary gateway for the submission of claims. Availity immediately sends the claim to Humana for adjudication. Humana's system returns the adjudicated claim through Availity to the provider's office. Within 30 seconds, the provider's office knows exactly what to charge the Humana member. It can be instantly deducted from his/her health care savings account (HSA), health reimbursement arrangement (HRA) and/or flexible spending account (FSA) using the HumanaAccess Visa card. Humana's portion of the claim is paid in the normal weekly cycle for electronic claims submission.

Humana is currently working with MacGregor Medical Center in San Antonio, along with others, to provide the primary care practice with real-time claims adjudication capabilities.

"There's no doubt that we have seen cash flow benefits," said Terri Foose, CFO of MacGregor Medical Center. "But in addition to that, we have seen improvements in patient satisfaction and in our ability to communicate with them. We are also realizing a savings in the cost of sending statements, rebilling and talking to patients about charges over the telephone. It (Humana's real-time claims adjudication solution) has made for a much more efficient operation."

As the adoption of HDHPs grows, providers have faced difficulty with knowing how much money to collect from patients at the time of service. Because these plans include deductibles, providers need to know whether the patient has met his/her deductible in order to know the portion of the claim for which the member is responsible.

"The idea of real-time claims adjudication initiative is a step in the right direction," said William Jessee, MD, FACMPE, president and chief executive officer of Medical Group Management Association (MGMA). "It is a start toward a much-needed solution to one of the greatest problems faced by medical group practices' administrative complexity in the payment system. We support national, multi-payer solutions to this problem, and we appreciate Humana's leadership."

Throughout 2006, Humana will roll out real-time claims adjudication to other providers across the country. To encourage acceptance of this opportunity, Humana is also working with ZirMed, Inc. to develop solutions that provide real-time claims adjudication capabilities without costly integration with the providers' information or practice management system.

About Humana

Humana Inc., headquartered in Louisville, Ky., is one of the nation's largest publicly traded health benefits companies, with approximately 7 million medical members. Humana offers a diversified portfolio of health insurance products and related services - through traditional and consumer-choice plans - to employer groups, government-sponsored plans and individuals.

Over its 45-year history, Humana has consistently seized opportunities to meet changing customer needs. Today, the company is a leader in consumer engagement, providing guidance that leads to lower costs and a better health plan experience throughout its diversified customer portfolio.

More information regarding Humana is available to investors via the Investor Relations page of the company's website at www.humana.com, including copies of:

-- Annual report to stockholders

-- Securities and Exchange Commission filings

-- Most recent investor conference presentation

-- Quarterly earnings news releases

-- Replay of most recent earnings release conference call

-- Calendar of events (includes upcoming earnings conference call dates, times, and access number, as well as planned interaction with institutional investors)

-- Corporate Governance Information


Humana Corporate Communications
Dick Brown, 502-580-3683