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Points of Light 2025 Case Study 9
Improving the Adjudication Process for Inpatient Claims Between Healthcare & Payer Organizations
Author
Boyd Stewart
Author
Aurene Wilford
At times, payer organizations need to request charts from hospitals in order to obtain the clinical evidence needed for inpatient diagnosis-related group (DRG) claims processing. This can result in delays in claims decisions and payments, an increased administrative burden, and operational inefficiencies. In this collaboration, Aetna used Epic Payer Platform to connect to health systems; the payer also built a FHIR-enabled data repository to store member clinical data. Together with OSF HealthCare, the parties were able to decrease chart requests and turnaround times for claims reviews, leading to increased efficiencies and quicker payments.
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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
Writer
Natalie Hopkins
Designer
Jess Wallace-Simpson
Project Manager
Joel Sanchez
This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2025 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.