Company begins real-time adjudication of claims

Here is what you owe

Providers would love to reduce the number of days it takes to have claims paid. Now a company is actually adjudicating and resolving claims in real time.

RealMed Corp., based in Indianapolis, is currently targeting the top 10 largest and progressive payer organizations in the country in its effort to provide end-to-end resolution of claims at the point of service. The system is used primarily in outpatient environments.

"To bring value to the provider, you need enough of their payers so that it warrants them using a new system," says Todd Morris, RealMed’s vice president of marketing. "Typically we look to payer organizations that have 25% to 30% of a specific geography’s patients. Once we have that, we go out and make the offer [of the system] to the health care provider organizations."

After RealMed has successfully integrated all the major payers, it expects the adoption of the platform to weave across the health care industry.

"It will take some time, but we are starting by focusing on the large payers that deliver the greatest number of claims for our specific providers," Morris says. RealMed has actively integrated with three of the payers, and is in varying stages of discussion with others.

Real-time claim resolution is attractive to payers that want to increase their level of service to payers and members, he says. In addition, payers find they can save more on administrative costs by using such a system than they can by holding the money. Actuarial firm Milliman & Robertson in Seattle estimates RealMed’s system will save payers more than 75% in per-claim processing and customer service costs up to $8.25 per claim.

Building a network

RealMed electronically links insurance and managed care companies, physicians, and health care providers, and ultimately, patients through its RealMed Network. The network processes data and dollars much like a retail credit card transaction.

Components of the network include:

RealMed for health care providers.

This is a claims resolution package that includes software, a smart card reader, office smart cards, and help desk support. RealMed for health care providers links the provider to the network and offers real-time patient check-in, eligibility verification, referrals, precertification, claim submission, claim repricing, interactive adjudication, credit/ debit card transactions and printing of explanation of benefits (EOBs) at the point of service.

RealMed for payers.

This integration interfaces with a payer’s current claims adjudication engine to enable interactive adjudication directly with health care providers. Typically, this requires a multimillion dollar, six-month integration effort.

Insured smart card.

This is a plastic card containing a microchip that functions both as a microprocessor and as a storage device for a unique patient identifier. If a payer elects not to provide smart cards to its members, the system may be accessed using a unique identification number.

"The [provider] logs on to the system in the morning using its RealMed smart card," Morris explains. "The card unlocks the payment plan. When the member comes in, the provider can either enter the smart card or can key in the unique identifier for the patient. That sets off our linking with the payer organization to let the claim be resolved."

Taken as a whole, the visit to the health care provider becomes more like a standard retail transaction. Bills for services provided are settled at the point of care. "The providers link directly with the insurance company’s membership files, find out if the patient is indeed covered, how much of the deductible has been met, and what the copay is," Morris says.

By showing how much insurance will pay on a claim, providers can collect from the patient or make arrangements for the collection of payment face to face as opposed to using letters and billing statements. "This reduces write-offs from patients," he says. (For information on patients who want to manage their health insurance benefits on-line, see story at right.)

The process step by step

Here is an example of how the RealMed process might work when a patient comes in to a provider’s facility for treatment:


The patient presents a health insurance smart card or current ID card; an electronic check-in file is opened and presents the precise demographic and insurance information from the payer’s Legacy system.

Eligibility verification.

The office staff verifies eligibility on-line in real time by connecting to the universal RealMed payment center.


The patient sees the provider for diagnosis and treatment.

Claim submission.

Someone from the office staff files an electronic claim form to the payer organization. (Hospitals can submit both their HCFA 1500 and UB92 claims.) Comprehensive on-line edits ensure the claim is complete.

Repricing and adjudication.

RealMed for Payers links with the payer’s existing adjudication engine to reprice and adjudicate the claim and returns the claim to the health care provider for acceptance within seconds; if an error is found, the office immediately receives an on-line notice.

Resolution and payment.

An electronic funds transfer is then ordered from the payer to cover treatment costs, and a customized EOB is printed for both the provider and patient records. The physician can collect the copay/co-insurance from the patient on the spot.

Coming soon to your town

Providers who are wondering if they can use real-time payments should check with their payers to see if they are considering offering the system.

"For so long, providers have been fighting just to get paid at the base levels that they have negotiated," Morris says. "We’re happy to help them collect on that."

[For more information, contact RealMed at (877) REALMED or go to the Web site at http://www.real]