Real-Time Claim Adjudication a "new" way to look at collecting your money

In a time where we are reminded daily that much of the current technologies (EHR, HIE, EDI, and others) will reduce medical error, improve patient care, we tend to overlook the prolific results that other technologies have to offer to health organizations. The market offers that great solutions that billing departments across the nation would appreciate how it can reduce claim denials, put money in the bank much quicker and overall improve the practices bottom line.

Real-time claim adjudication (RTCA) is a solution that enable medical organizations to bill for services before the patient leaves the practice. This allows for the organization to submit a claim with the procedures performed and get a response displaying the allowable charges and patients remainder responsibility based on the contractual agreement.


This has been around for some payers in some states. Humana, some Blue Cross Blue Shied of some states (BCBS of NC has started the development but has not officially released any target dates). Some PMS vendors have been able to successfully enable practices to take advantage of this functionality. AthenaHealth was one of those vendors, with their RTA (Real time Adjudication) services, it makes for a very attractive model for any practice looking to lower the denial rate on their claims.


Using Real Time adjudication is a no brainer when one begins to realize how much time is spent on claim filing, refiling and working the denials. It is known that insurance eligibility verification does resolve some of the claim denial issues, however, much of the billing departments pains lies in dealing with payers who may deny some procedures and not others within the same claim, and then the battle to explain to the patient why they are now responsible for the balance.

According to some recent MGMA statistics published in http://www.mgma.com/SwipeITWaste/ we can see some of the costs associated with claim denials:

57,168,299 Number of claims per year that must be resubmitted due to payer denial due to incorrect patient demographics from non-electronic registration


857,524,484 Minutes per year to resubmit claims denied due to payer denial due to incorrect patient demographics from non-electronic registration


14,292,075 Hours per year to resubmit claims denied due to payer denial due to incorrect patient demographics from non‐electronic registration

289,762,993 Dollars saved per year by not having to resubmit claims denied due to payer denial due to incorrect patient demographics from non-electronic registration


While in the perfect world RTCA would work so well with an EHR, especially when the provider can submit the encounter electronically right after the visit, it is important to note that even if a physician write the data or circles the procedures and diagnosis on the paper charge sheet, the checkout individual may have the ability (depending on the Practice Management System) to perform the RTCA task and benefit from this wonderful technology.