During
the
annual
HLTH
conference
in
Las
Vegas
this
week,
Optum,
the
data
analytics
subsidiary
of
UnitedHealth
Group,
announced
the
launch
of
Optum
Real,
a
real-time
claims
management
system
that
is
designed
to
remove
the
friction
between
providers
and
payers
when
it
comes
to
submitting
claims
and
getting
reimbursed
in
a
timely
manner.
The
announcement
is
not
a
moment
too
soon,
given
that
provider
resentment
against
what
they
believe
is
a
policy
of
“delay
and
deny”
by
insurers
has
reached
a
boiling
point.
Executives
from
the
company
took
the
stage
at
HLTH
to
explain
how
the
vast
majority
of
claims
get
processed
quickly
and
it
is
just
a
few
that
gives
people
headaches.
The
reason
for
this:
lack
of
transparency.
“If
I
have
to
summarize
it
in
one
word,
I
would
say
the
biggest
challenge
in
claims
and
reimbursement
is
guesswork,”
said
Puneet
Maheshwari,
senior
vice
president
and
general
manager
of
Optum
Real,
to
the
audience
on
Tuesday.
“The
guesswork
that
happens
on
the
provider
side,
the
guesswork
that
happens
on
the
payer
side,
leads
to
significant
amounts
of
work
and
overhead
for
both
parties
involved
…”
Enter
Optum
Real.
According
to
the
Minnesota
company’s
press
release,
Optum
Real
is
a
“multi-payer
platform
[that]
allows
real-time
data
exchange
between
payers
and
providers,
enabling
the
identification
and
interception
of
known
issues
at
the
point
of
claim
submission.”
Given
that
Optum
developed
the
system
that
promises
“instant
clarity,”
it’s
no
surprise
that
UnitedHealthcare,
a
sister
company
under
the
UHG
umbrella,
is
the
first
health
plan
in
the
country
to
adopt
this
technology.
In
an
interview
following
the
panel
discussion
on
stage,
Maheshwari
declared
that
Optum
Real
was
designed
to
remove
the
data
fragmentation
that
hobbles
the
claims
adjustment
process
and
can
save
the
millions
of
dollars
that
providers
pay
clinical
documentation
improvement
teams
to
increase
their
chances
of
getting
reimburses
and
the
millions
of
dollars
that
payers
pay
claims
integration
companies
to
make
sure
providers
are
doing
everything
by
the
book.
Here’s
a
lightly
edited
Q&A
of
the
discussion.
MedCity
News:
You
are
calling
it
real
time,
but
nothing
in
healthcare
is
actually
real
time,
right?
It’s
not
like
seeing
your
Uber
Eats
meal
arriving
in
the
car
in
real
time.
Healthcare
uses
that
term
loosely,
correct
me
if
I’m
wrong,
But
what
do
you
mean
by
real-time,
actually?
Maheshwari:
Yeah.
So
I
would
say
the
observation
is
very
astute.
The
aspiration
is
to
make
it
real-time,
in
earnest
real-time.
Let’s
look
at
the
process
today
for
a
simple
ambulatory
example.
By
the
end
of
the
day
or
two
days
after
the
encounter
with
the
provider,
the
provider
completes
the
documentation,
but
by
then
information
is
already
lost.
Then,
in
batch
mode,
it
gets
sent
to
the
clinical
documentation
improvement
team
(CDI).
If
it
is
not
complete,
then
it
goes
back
to
the
provider
to
get
it
completed.
Then,
in
batch
mode,
it
goes
to
the
coding
team,
and
if
they
find
errors,
they
go
upstream
and
change
those
errors.
Then
in
batch
mode
it
goes
to
the
claims
team
that
scrubs
the
claims
based
on
payer-specific
rules.
Then
they
send
it
in
batch
mode
to
a
clearing
house,
which
run
a
set
of
checks,
sends
it
to
the
payer
who
signs
a
set
of
checks.
Happy
case.
Everything
works
out
fine
and
it
takes
two
to
three
weeks.
On
a
bad
case,
it
can
take
months.
That’s
a
case
when
something
gets
returned
because
there
was
an
administrative
error
or
the
payer
did
not
have
enough
information
to
approve
it
right
away.
Then
the
back
and
forth
begins
and
that
can
take
anywhere
from
the
same
cycle
all
over
again
to
even
more
cycles.
So
that’s
the
current
state
and
the
reason
for
that
current
state
is
because
there’s
lack
of
transparency
between
payers
and
providers.
They
try
to
do
it
with
guesswork.
What
real-time
transparency
enables
is
that
it
removes
the
guesswork.
Real
transformation
comes
when
you
can
ask
these
real-time
queries
in
the
moment
of
care
that
really
matters
when
you
can
make
the
right
decisions.
For
example,
a
patient
is
walking
in
for
an
MRI.
Are
they
covered
for
this?
This
requires
the
provider
to
ask
the
question
to
the
payer.
Then
it
requires
the
payer
to
understand
what
are
the
benefits,
what
are
the
contract
with
the
particular
provider,
what
is
the
guideline
against
which
MRI
is
approved
or
not,
and
then
give
a
referral
and
along
with
that
give
clarity
around
how
much
the
provider
is
going
to
be
paid
and
how
much
is
the
patient
liability.
That
capability
before
the
service
even
exists
is
what
we
are
bringing
to
life
with
Optum
Real.
A
brain
MRI
with
or
without
contrast
doesn’t
have
a
lot
of
variability.
But
somebody
walks
in
because
they
have
a
cut
in
their
hand
–
you
don’t
know
what
all
will
be
done
in
the
exam.
They
may
get
sutures.
They
may
then
get
a
tetanus
shot.
They
may
be
given
additional
support
because
they’re
diabetic
and
they
don’t
heal
easily.
So
the
complexity
of
the
case
could
be
very
different
depending
on
who
is
getting
that
cut
and
not
just
that.
Whether
the
cut
is
a
three-centimeter
cut
or
a
five-centimeter
cut
will
change
how
it’s
coded
in
the
encounter.
So
that
variability
can
be
addressed
with
capabilities
today,
where
an
ambient
scribing
capability
can
scribe
the
encounter
in
real
time.
Now
if
that
happens,
we
can
bring
in
and
we
are
bringing
in
capabilities
to
assess
whether
the
documentation
is
complete
and
accurate.
The
example
of
three
versus
five
centimeters.
Right
there
you
can
say
…
‘hey,
you
forgot
the
length
of
the
type
of
suture
and
can
you
provide
me
the
length
of
the
cut?’
And
as
soon
as
the
documentation
is
complete,
I
can
autonomously
code
it.
I
can
autonomously
fill
it
and
get
the
response
from
the
payer
in
real
time
on
whether
this
claim
or
inquiry
of
the
claim
will
get
approved.
We
can
answer,
‘how
much
is
the
patient
liable?’,
‘how
much
would
the
provider
get
paid?’.
Before
the
patient
gets
out
of
the
exam
room,
all
of
this
is
done
and
teed
up,
making
that
three-week
four-week
process
that
we
discussed
collapsed
down
to
the
point
of
checkup.
MedCity
News:
So
this
seems
super
rosy
to
me
because
everything
in
healthcare
is
so
slow.
I
understand
that
providers
are
using
ambient
technologies
and
some
ambient
technologies
have
the
ability
to
document
and
code.
So
providers
can
create
that
perfect
note.
I
get
all
of
that,
but
I
am
still
not
sure
that
providers
have
the
ability
to
completely
understand
what
you
need
unless
you
share
your
protocols
with
them
clearly,
that
‘okay,
this
is
going
to
get
paid
and
this
is
not
going
to
be.’
Maheshwari:
That’s
exactly
why
this
solution
is
different
than
anything
else.
Everybody
who’s
looking
at
reimbursement
solutions
and
AI
today
is
saying,
‘Can
I
build
a
better
AI
for
the
provider?’
And
then
the
other
side
is
saying,
‘Can
I
build
a
better
AI
for
the
payer’
so
that
they
can
compete
with
the
AI
of
the
provider,
right?
So
what
used
to
be
a
competition
between
rule-based
systems
is
turning
into
competition
of
AI.
We’ll
end
up
at
the
same
place
all
over
again.
The
way
to
solve
it
is
to
create
that
real-time
transparency.
You’re
right
that
the
payers
have
historically
been
cagey
—
for
lack
of
a
good
word
—
in
terms
of
creating
that
full
transparency,
but
what
we
have
going
for
us
is
that
…
UnitedHealthcare
has
opened
up
these
APIs
that
will
provide
real-time
transparency
into
these
queries
on
the
payer
at
a
very
high
level
of
precision
of
not
just
saying,
‘Puneet
is
eligible
for
this
thing,”
but
to
a
level
of
specificity
that
says,
‘Puneet
is
eligible
for
this
thing
against
the
specific
diagnosis
code
Puneet
has
for
the
benefit
structure
that
he
has
for
the
contract
that
I
have
with
his
particular
provider.’
That
decision
has
been
missing
in
the
past.
MedCity
News:
The
insurance
business
model
is
simple,
right?
You
are
a
for-profit
entity,
and
the
way
you
make
money
is
that
you
pay
out
fewer
claims
than
you
bring
in
as
premiums.
Now,
if
you
create
a
transparent
system
where
you
are
providing
your
protocols,
then
you
are,
in
a
way,
threatening
your
own
business
model.
Are
you
not?
Maheshwari:
So
if
you
look
at
the
statistics,
the
numbers
tell
a
different
story.
When
a
provider
submits
claims,
80%
of
them
get
approved
and
get
paid.
Roughly
10%
to
20%
get
reworked.
The
majority
of
that
rework
happens
because
the
payer
doesn’t
have
enough
information
to
pay
the
claim
…
and
the
provider
has
some
level
of
problems
in
the
claim
or
there
are
errors.
[Note
here
that
Maheshwari
seems
to
imply
that
all
errors/problems
or
lack
of
information
in
the
claim
lie
necessarily
on
the
provider
side.
I
personally
have
been
in
situations
where
I
fought
my
insurance
company
after
they
provided
incorrect
provider
network
information
to
me.
I
was
only
partial
reimbursed
from
the
payer
even
though
the
fault
for
providing
wrong
information
lay
completely
with
the
payer.
The
payer
in
that
case
was
not
UnitedHealthcare,
however.]
The
final
denial
rate
that
happens
because
of
medical
necessity
is
in
the
low
single
digits.
So
all
this
overhead
that
happens
between
payers
and
providers
for
those
first
time
returns
is
getting
completely
eliminated
with
Optum
Real.
Now,
I
as
the
payer,
and
you,
as
the
provider,
can
still
debate
whether
this
was
medically
necessary
or
not.
But
that
number
of
denial
is
2%
to
3%.
The
remaining
is
administrative
overhead.
But
you
can
take
it
even
a
step
further.
Even
for
the
80%
that
gets
reimbursed
in
2
weeks,
there’s
a
$250
billion
RCM
industry
sitting
on
the
provider
side
and
there
is
roughly
a
$100
billion
on
the
payer
side
in
payment
integrity.
So
the
industry
is
spending
anywhere
from
$300
billion
–
$350
billion
so
that
the
provider
gets
paid
for
the
service
that
they
have
delivered
for
claims
that
fall
in
the
approved
80%
category.
Now,
if
we
create
this
real-time
transparent
system,
you
get
dramatic
efficiency.
MedCity
News:
So
is
Optum
Real
trying
to
put
these
RCM
and
payment
integrity
industries
out
of
business?
Maheshwari:
Putting
out
of
business
is
probably
a
much
more,
I
would
say
aspirational,
aggressive
statement.
I
would
definitely
say
that
we
owe
it
to
ourselves
as
patients,
payers
and
providers
to
take
down
the
administrative
waste
and
administrative
hurdles
that
we
have.
———————————
Does
this
mean
the
era
of
“delay
and
deny”
—
as
the
tactics
of
insurance
companies
have
been
routinely
described
—
is
officially
over?
Allina
Health,
a
health
system
based
in
Minnesota
where
UHG
is
also
headquartered
has
apparently
seen
great
savings
through
Optum
Real,
according
to
the
Optum’s
news
release.
As
for
providers
in
the
rest
of
the
country,
only
time
will
tell.
We
invite
providers
to
reach
out
to
us
if
your
experience
with
UnitedHealthcare
claims
and
reimbursement
systems
materially
improves
as
a
result
of
Optum
Real.
And
in
the
meantime,
we
at
MedCity
News
will
be
keeping
it
real.