By NextBestFitOne claims system and standard rules
One claims format, one set of codes and rules, real-time payment.
One claims system under one payer.
Review ledgerHow this path connects
This path
One claims system and standard rules
Requires:
Single public payer for everyoneTens of millions of people have no coverageChosenConcrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Build one national claims system with standard codes
- Pay claims in real time
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- About $1 trillion a year in administrative cost
A common claims format, codes, and rules produces substantial savings for providers and payers. Immediate payment ends accounts receivable.
What it creates or worsens
- Requires new or changing information systems
Building a unified claims and payment system is a large information technology project with a risk of failure.
- Cyberattacks can halt payments and care
Concentrating claims in a single system makes that system a target for cyberattacks.
Who's affected
Who gains
- Doctors, nurses, and other clinicians
- About $1 trillion a year in administrative cost: Time goes to billing and insurer rules instead of patients.
- People with employer coverage
- About $1 trillion a year in administrative cost: Premiums pay for the administration.
- Taxpayers and public budgets
- About $1 trillion a year in administrative cost: Public programs pay for it too.
- Hospitals, clinics, and care organizations
- About $1 trillion a year in administrative cost: A common claims format, codes, and rules produces substantial savings for providers and payers. Immediate payment ends accounts receivable.
- Fraudulent operators and cybercriminals
- Cyberattacks can halt payments and care: Attackers profit from ransomware attacks on health systems.
Who loses
- Health insurers, brokers, and their shareholders
- About $1 trillion a year in administrative cost: Insurers, billing firms, and clearinghouses earn from the complexity.
- Insurance and billing workers
- About $1 trillion a year in administrative cost: Their jobs exist because of the complexity.
- Health administration and software vendors
- Requires new or changing information systems: Building a unified claims and payment system is a large information technology project with a risk of failure.
- Hospitals, clinics, and care organizations
- Cyberattacks can halt payments and care: Cyberattacks disrupt claims and leave providers unpaid.
- People with employer coverage
- Cyberattacks can halt payments and care: Cyberattacks expose personal health data.
- Uninsured people
- Cyberattacks can halt payments and care: Cyberattacks expose personal health data.
- People with unaffordable deductibles or coinsurance
- Cyberattacks can halt payments and care: Cyberattacks expose personal health data.
Other ways to soften the losses
- Retrain clearinghouse staff
Where it has been tried
- Taiwan: Single electronic claims system.