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Home / News & IndustryManaged Care Insight and Analysis
Updated: November 3, 2009
Health Plan Develops Real-Time Claims Tools

Helps Providers And Members Get Handle on Payments, Co-Pays

Hospitals, ambulatory surgical centers, imaging setters and other types of healthcare providers can determine a member’s financial obligation before a service is rendered and collect payment when the member receives care using real-time tools developed by Highmark.

Some 250 providers in Highmark’s 49-county service area in western and central Pennsylvania began using real-time tools last November, and during the first two months of this year providers submitted nearly 10,000 transactions that identified approximately $395,000 worth of payments due frommembers, the health plan said.

"These real-time capabilities are especially helpful to Highmark members with high deductibles, coinsurance or other cost sharing, to better understand the actual cost of healthcare services," the health plan said. Some 730,000 Highmark members are enrolled in health plans with cost sharing that include deductibles and/or coinsurance for a network services.

The health plan said real-time claims processing and real-time member liability estimation "assists physicians and other providers to receive payment for their services and relieves the guesswork for members about the cost of their medical treatment." Members know their actual out-of-pocket health care costs based on their benefits when they schedule or receive health care services.

Highmark said providers are telling the health plan that real-time claim processing has "enabled their patients to better comprehend the cost of services they have received, understand what they owe and more easily make payment arrangements."

In terms of provider reimbursement, the real-time tools have reduced reimbursement timing from Highmark to within three days instead of 15-20 days, the health plan said.

"All of Highmark providers are able to use the real-time tools through Highmark’s provider portal NaviNet." The health plan also said it is working with practice management system vendors to integrate the real-time tools with their software.

"This point of service payment method is also receiving favorable reviews from members," Highmark said. "More than 88 percent of members whose providers use real-time tools were satisfied with their experience."

For more information on Highmark, visit

  This article was taken from:
The Executive Report on Managed Care

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