Deal expands real-time claims adjudication

Two health-plan-owned electronic processing ventures are melding into one in an attempt to rev up the development of real-time claims adjudication -- settling the insurer's and patient's share of payment before the patient leaves the office.

The joint venture combines Jacksonville, Fla.-based Availity, an Internet-based claims processing company operated by Humana and BlueCross and BlueShield of Florida, and The Health Information Network, or THIN, an electronic claims processing company based in Dallas and operated by Health Care Service Corp., which owns Blues plans in Illinois, New Mexico, Oklahoma and Texas.

The venture, operating under the Availity name, expects to handle 330 million transactions, representing $50 million in revenue, over the course of the next year. The venture -- which is not being called a merger, because Availity is acquiring THIN's contracts, not its assets -- is awaiting antitrust approval, expected to come sometime over the summer.

The deal would expand Availity's network of 14,000 doctors and hospitals by an additional 120,000 doctors and hospitals.

Availity has been an early leader in developing software for real-time claims adjudication, which THIN does not currently offer. Availity CEO Julie Klapstein said physicians who contract with one of plans in the joint venture would receive the company's Internet software free of charge.

Real-time claims adjudication is often cited as key to the success of consumer-directed health plans, because all parties are able to know almost instantly what the insurer is paying and what the patient is paying, assuming the claim is accepted as is by the plan. Insurers also say it reduces their administrative costs, while some physicians say they welcome it because it could improve their cash flow.

"Our margins are so slim and our cash flow is so crucial to the function of the practice, it would be tremendously helpful," said J. Gregory Cooper, MD, a family physician in Cynthiana, Ky., who files claims electronically but does not yet have access to real-time claims adjudication. "Lots of times the delay in payment seems to be a way that [insurers] use the money that physicians have earned, so this would go a long way to promoting trust and making physicians feel encouraged about the companies that pay for the services we provide."