Christopher Fisher, maxRTE Business Development Director


It’s not the lottery. It’s the staggering number that the 2017 CAQH Index projected healthcare administrative costs to reach by the end of that year—nearly what the combined 10 highest-spending state Medicaid programs paid in 2016 to provide care for more than 46 million beneficiaries. And unless you’ve gone totally electronic, part of those costs belong to your organization.

Healthcare in the U.S. has gotten complicated, burdensome, and costly—for provider organizations and patients. Costs associated with billing and insurance-related administrative activities continue to rise, with continued use of manual business processes—using phone, fax, or email—to conduct claims-related transactions.


Mediocre progress

According to the 2017 CAQH Index’s assessment, the transition toward fully electronic administrative transactions showed only modest progress. Overall, adoption of at least one electronic transaction, prior authorization, is only in the single digits, which includes the use of portals.

While portals offer health plans a highly automated solution, these systems are still burdensome for providers, requiring them to sign on and navigate a different online system for each health plan with which the provider is contracted. However, some systems, such as maxRTE, have overcome this navigation obstacle.


Growing potential for savings

More transactions mean more savings. According to Index estimates, the industry can save $11.1 billion by transitioning to electronic transactions—a one-year increase of $1.8 billion.

The per-member per-year transaction count rose from 17 inquiries in 2016 to 18 in 2017, and the per-claim count rose from 1.7 to 1.8. Health plans fielded more than 84 million telephone inquiries from providers.  Transaction volume growth has been driven by:

  • More insured persons under the Affordable Care Act (ACA)
  • Rising use of complex insurance products, such as high-deductible health plans (HDHPs) spawning more benefit questions and claims
  • Availability of real-time information through electronic eligibility and benefit and claim status transactions

Essentially, more patients don’t understand their benefits, and providers want to know patient financial responsibility and the status of claims. The volume of eligibility and benefit verification transactions far outpaces that of all others tracked. Also, some non-provider entities use eligibility and benefit verification transactions for coordination of benefits and other services for providers (e.g., state Medicaid plans and third-party benefit verification services).


Real-time means real savings

Federally mandated CAQH CORE® Phase II Operating Rules that require real-time access to patient eligibility and benefit information intend to increase the likelihood that a provider will check patient eligibility. The Operating Rules are intended to improve productivity by offering access to information more quickly than a telephone inquiry. Real-time access also helps providers identify potential payment issues before they occur—a plus for both providers and patients.

Don’t let these types of transactions be an ongoing source of cost and inefficiency for your organization. A budget-friendly vendor whose software checks all of your payers for eligibility and benefits with a single click will save staff time, rein in collection costs, and keep patients informed.


maxRTE has been helping healthcare providers shorten the revenue cycle for more than 20 years. With maxRTE, just one click validates plan-specific benefit data such as patient coverage effective dates, co-pays and deductible information. Visit maxrte.comfor your free web demo.