Debunking three common misconceptions about gateway edits

As the product line manager for Availity Editing Services, I talk with a lot of health plans about how they can improve their clean claim rate by taking advantage of the editing capabilities in Availity’s Intelligent Gateway. Editing in the gateway not only helps improve operational savings for health plans, but also helps providers avoid denials and reduce days waiting for payment.

However, I have found there are a few common misconceptions about gateway editing that give some health plans pause. I thought it would be helpful to identify and address those misconceptions.

Misconception 1: We already have claims editing. How is this different?  

Most health plans do have editing integrated within their adjudication systems, such as post-adjudication and pre-payment editing, which ensure proper processing and payment of claims. But once a bad claim gets into the health plan, it still needs to be worked in some way, or there is a cost associated. The estimated cost of reworking a bad claim can range from $2 to $5 per claim.

Correcting edits in the EDI stream means fewer bad claims reach the health plan in the first place, which means avoiding rework costs and other overhead. 

Misconception 2: More edits mean more abrasion for my providers.

Some health plans worry that overly strict claim edits will confuse providers and lead to more support calls. This is a valid concern, but there are a few ways we can minimize it. First, when a claim is flagged and returned to the provider, it includes a message with an easy-to-understand explanation of why it was returned. This gives the provider information to correct this specific claim and to put in processes to prevent these issues in the future. 

In fact, gateway edits are likely to reduce abrasion, not increase it. When edits are implemented and providers see the reason for rejection, they are more likely to adapt to the change, which helps streamline their revenue cycle.    

Misconception 3: This will be a big lift on our side and cause operational disruption. 

While there is some process work required of health plans, it doesn’t have to be overwhelming. Implementing edits is a lot like creating a new habit. You’re more likely to be successful if you make small, incremental changes rather than making major changes all at once. In fact, we recommend starting with a smaller set of edits—ideally incorporating initial edits based on specific issues your health plan faces. By providing consultative support, our team of analysts will work with your plan to identify short-term opportunities and support longer-term strategies.

Gateway editing represents a potentially significant savings opportunity for health plans, so I hope these explanations answered any questions or concerns you might have. If you’re ready to learn more, visit our Availity Editing Services page.