Healthcare developers building everything from clinical trial analytics to claim dispute services need reliable insurance payment data. But there's a critical challenge: every insurance company encodes its payment calculations differently, making it nearly impossible to consistently track costs and coverage across payers.
In the following technical deep-dive, Flexpa engineers Dylan and Kyle examine real-world challenges in processing insurance payment data. Through detailed spreadsheet examples, they demonstrate how payment codes vary dramatically between different insurance companies and even across different types of claims (like pharmacy vs. hospital visits) within the same insurance company.
The discussion covers:
- The basics of insurance claim adjudication and key payment values like benefits, member liability, and discounts
- How the same financial data can mean different things across different insurers (e.g., one payer's "benefit amount" being another's "eligible amount")
- Real examples showing how missing payment codes can mask significant patient costs
Looking ahead: With CMS-0057-F on the horizon mandating payer-to-payer data exchange, consistent payment data standardization will become even more crucial. If you're an insurance company preparing for these requirements, we'd love to talk – check out our recent Payer Patient Access API Report and reach out to learn how Flexpa can help.
