Partner:
UnitedHealthcare Group (UHG) – One of the largest commercial health insurance providers in the U.S., processing millions of claims annually.
The Challenge:
Traditionally, healthcare providers submit claims through third-party clearinghouses such as Availity or Optum. While this system is reliable, it introduces several inefficiencies:
- Slower Payment Times: For UnitedHealthcare, claims submitted via clearinghouses were taking 30-45 days to process. This lag was due to several factors in the claims handling process, many of which are not fully visible.
- SFTP-based Systems: The clearinghouses largely rely on batch submissions through SFTP, which limits the responsiveness and flexibility needed for faster claim handling.
- API Access Costs: Providers are charged for using clearinghouse APIs, which have limitations and add steps to the process, slowing real-time response capabilities.
- Standardized Data: Clearinghouses offer limited visibility into detailed patient information, often providing only standardized responses that lack the full range of data available directly from insurers.
Our Solution:
We partnered with UnitedHealthcare to offer healthcare providers an alternative to the clearinghouse model by enabling direct API claims submission. This new solution provides real-time, direct interaction with UnitedHealthcare’s backend claims processing systems, removing unnecessary middle steps and improving overall efficiency.
- Direct API Integration: The API now allows providers to submit 837p claims (both institutional and professional) directly to UnitedHealthcare. This bypasses the traditional clearinghouse model, offering a much faster, more efficient method for claims handling.
- Collaborative Development: Working hand-in-hand with UnitedHealthcare’s technical and business teams, we completed the first end-to-end test of the direct claims submission API, achieving a full integration in under three weeks—a process that was expected to take at least three months.
- Enhanced Automation: The API-driven system is easily automated and scales efficiently with claim volume, ensuring stable, reliable performance as the system grows. This is the ideal method for larger provider groups and hospital systems.
Outcomes:
- Accelerated Payment Cycles: The claim-to-payment flow was reduced from 30-45 days to 14-20 days. This improvement is significant, especially when scaled across large volumes of claims.
- Real-Time Acknowledgements: Providers now receive immediate 277CA claim status acknowledgments, eliminating delays typically seen with clearinghouse submissions.
- Cost Savings: All providers can now submit claims directly to UnitedHealthcare without any additional fees, bypassing clearinghouse costs entirely.
- Richer Data, Faster: Direct API calls provide more detailed, actionable claim status information than what’s available through clearinghouse APIs today, improving visibility and offering real-time tracking for providers.
- Industry-Leading Standard: UnitedHealthcare is now the first major U.S. commercial payer to adopt direct API-based claim submission. This step forward sets a new industry standard, demonstrating how claims submittal and processing can be faster, more efficient, and more transparent without relying on third-party intermediaries.
Learn More:
Daniel Vidaud, Strategic Implementation Advising: daniel@personalizedtransformations.com
UnitedHealthcare API Consultants are available at: apiconsultant@uhc.com
