Claims Management & Clearinghouse Software Product Ranking Comparison

Manual prior authorization workflows are time consuming and costly for payer and provider organizations and can delay patient access to care. To increase provider visibility into which services require prior authorization and to bring automation to the submission and decision processes, the collaborators in this case study worked together to develop a more automated, self-service solution that allows providers to determine whether a given service requires prior authorization, submit a request, and receive a determination, all within their EMR workflow. The technology has improved efficiency, reduced denials, and increased revenue.

Report Abstract

Key Findings:

Executive Summary
The Collaborators
Points of Friction—Challenges to Be Solved
Action Plan—How the Collaborators Worked Together to Reduce Friction
Points of Light—Outcomes Achieved through Collaboration
Lessons Learned—What Best Practices Can Other Organizations Replicate?
What's Next?—Vision for the Future

Performance Data

Overall Score by Product

Products Appearing in Decisions

Overall Score by Question Topic

Provider Facility Size by Product

Provider Facility Type by Product

To reduce the manual work associated with claims monitoring, the partners in this case study collaborated to combine API technology from the payer with robotic process automation (RPA) technology from Waystar. Claims statuses are then normalized and delivered directly into the healthcare organization’s EMR workflows, resulting in greater claims visibility and a reduced administrative burden for all parties. As a result of this collaboration, the healthcare organization has also seen reduced denials and faster payment collection.

The financial well-being of healthcare organizations is critical, especially given the macroeconomic pressures they face today. Many are looking at claims management and clearinghouse technology to maximize cash collections and reduce administrative burdens. To better understand what factors are influencing purchase decisions and which vendors are seen as capable of driving success, this report examines 24 recent purchase decisions validated by KLAS between February 2020 and November 2022. For additional context, satisfaction data from current customers is also included. It should be noted that the decisions in this report are not a comprehensive representation of all claims management purchase decisions made in the last several years.

Perception

Optum/Change Healthcare Merger

16 August 22 | Boyd Stewart and Sam Eaquinto

In January 2021, Optum announced their intentions to acquire Change Healthcare. The merger remains unfinalized, however, as the US Department of Justice blocked the deal in February 2022 due to anticompetition concerns—such a merger would give UnitedHealth Group, Optum’s parent company and the nation’s largest insurer, access to rivals’ sensitive data. The legal proceeding is ongoing and scheduled to go to trial August 1, 2022. This report shares Optum and Change Healthcare customers’ reactions to the merger and their perceptions of its impact. Between March 2021 and April 2022, KLAS interviewed 48 individuals from 46 unique organizations; of these respondents, 9% are Optum customers, 56% are Change Healthcare customers, and 35% are customers of both vendors.

Claims Management & Clearinghouse

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